The Psychology of Decision

CHAPTER SIX
The Psychology of Decision

Making
Linda Hickson*,1, Ishita Khemka†
*Teachers College, Columbia University, New York, New York, USA
†
St. John’s University, Queens, New York, USA
1
Corresponding author: e-mail address: hickson@exchange.tc.columbia.edu
Contents
1. Theoretical Perspectives on Decision Making 186
1.1 Normative and Descriptive Theories 186
1.2 Dual-Process Theories 190
1.3 Role of Noncognitive Processes in Decision Making 192
1.4 Developmental Perspectives on Decision Making 196
1.5 Summary of Theoretical Perspectives on Decision Making 198
2. Decision Making and IDD 199
2.1 Research on Decision Making with Individuals with ID 200
2.2 Research on Decision Making with Individuals with WS—A Singular
Disorder Associated with ID 206
2.3 Research on Decision Making with Individuals with ASD 208
2.4 Summary of Decision-Making Research with Individuals with IDD 211
3. A Pathways Model of Decision Processing 212
4. Conclusion 218
References 222
Abstract
This chapter overviews general theoretical advances including developmental perspec-
tives in the study of decision-making behavior and their applicability in understanding
how individuals with intellectual and developmental disabilities (IDD) approach inter-
personal decisions in their lives. Of particular importance are the theoretical explications
of the roles of cognitive and noncognitive processes (e.g., motivation and emotion), and
the contextual demands of different decision tasks, as possible loci of the decision-
making difficulties observed in individuals with IDD. Extant decision-making research
with individuals with IDD is summarized and a Pathways of Decision Processing model
is outlined for the systematic study of their decision-making processes and building
adaptive decision-making strategies. The chapter examines distinct disability-specific
patterns of decision-making difficulties associated with underlying etiologies and phe-
nomenological characteristics of the subtypes of IDD, with implications for the need for
International Review of Research in Developmental Disabilities, Volume 47 # 2014 Elsevier Inc. 185
ISSN 2211-6095 All rights reserved.
http://dx.doi.org/10.1016/B978-0-12-800278-0.00006-3
186 Linda Hickson and Ishita Khemka
differentiated interventions to improve the decision making of individuals with different

forms of IDD, including those with intellectual disabilities, Williams syndrome, and
autism spectrum disorders.
People with intellectual and developmental disabilities (IDD) are called

upon to make a variety of important decisions in their lives in the commu-
nity. Those decisions pertain to personal situations, such as decisions about
how to handle finances or whether to consent to a medical treatment, as well
as interpersonal situations. The effectiveness with which these decisions are
made can have a major impact on an individual’s quality of life. Unfortu-
nately, research has indicated that people with IDD often exhibit serious
shortcomings in their decision-making effectiveness. Such shortcomings
have been associated with increased vulnerability to abuse and victimization
and with a concomitant curtailment of their freedom and autonomy (e.g.,
Fisher, Moskowitz, & Hodapp, 2012; Hickson, Golden, Khemka, Urv, &
Yamusah, 1998; Hickson & Khemka, in press; Jenkinson, 1999;
Khemka & Hickson, 2000; Khemka, Hickson, Casella, Accetturi, &
Rooney, 2009; Luke, Clare, Ring, Redley, & Watson, 2012; Murphy &
Clare, 2003; Nettelbeck & Wilson, 2002).
The present chapter begins with a discussion of some general theoretical
issues in decision making in light of their applicability with individuals with
IDD. This is followed by an overview of research on decision making in
individuals with IDD and the presentation of our pathways model of deci-
sion processing. The chapter concludes with a discussion of implications for
future research and for the design of interventions to improve the decision-
making effectiveness of adolescents and adults with different forms of IDD,
including those with intellectual disabilities (ID), Williams syndrome (WS),
and autism spectrum disorders (ASDs).
1. THEORETICAL PERSPECTIVES ON DECISION MAKING

The concept of rationality is central to the study of decision making
(see Stanovich, 2010) and a variety of normative and descriptive theories
represent contentious views of the extent to which rationality controls
human decision making.
1.1. Normative and Descriptive Theories

Normative theories of decision making have provided prescriptions of
how people should make decisions. The theories provide prescriptive
Psychology of Decision Making 187
functions or decision rules to help people maximize expected utility of out-

comes. The normative rules serve as the rational standards to which peo-
ple’s actual behaviors are compared. The assumption underlying some of
these models has been that an optimal decision could be arrived at in a very
rational, mathematical sort of way (e.g., Byrnes, 1998; Gigerenzer &
Selten, 2001). However, people’s decision-making strategies have been
found to deviate from the principles of normative models in systematic
ways (see Galotti, 2002). Typically, decisions are made under conditions
of incomplete knowledge. The knowledge base of the decision-maker
may be insufficient or irrelevant to the decision at hand. For instance, in
many real-life situations, the outcomes of all possible options may not
be clear and people’s weightings of the different dimensions involved in
evaluating the options may change over time. Most importantly, the nor-
mative models often do not take into account the impossible processing
demands that they place on an individual’s cognitive system. Inherent con-
straints on people’s mental capacities have led researchers to consider alter-
native theories that take processing demands into account (Simon,
1957, 1986).
Descriptive theories of decision making, such as prospect theory
(Kahneman & Tversky, 1979), in contrast to the normative theories, delin-
eate how people actually make decisions in the face of certain and uncertain
events. It is hypothesized that people handle complexity in decision making
by selectively reducing problems to levels that are manageable in the real
world, thereby reducing the cognitive demands. The descriptive theories
are therefore less concerned with determining the ideal “rationality” of a
decision-maker and are more attentive to identifying the circumstances
under which decision-makers exhibit correct or fallacious reasoning
(Simon, 1986). Decision strategies refer to the processes that people under-
take to consider and evaluate the extent to which options serve their goals in
an acceptable way, even though the selected choice may not be the most
optimal one. Inherent in this approach is the thinking that decisions are
made within predictable capacity limits and decision-makers operate within
“bounded rationality” and that some instances of irrationality occur inevi-
tably in the decision making of human beings. As originally conceived by
Simon (1957), the construct of bounded rationality assumes that decision
making is guided by aspiration levels (or goals) which may be adapted if they
are too difficult to attain. The decision-maker searches for alternatives until a
satisfactory alternative is found that meets the aspiration level (also known as
“satisficing”) and is in accord with one’s capacity limitations (see Selten,
2001, for a fuller discussion).
1.1.1 Heuristics and Biases

The departure from normative theories has led researchers to examine the
kinds of heuristics that people use to make decisions (e.g., Gigerenzer &
Goldstein, 1996). Decision “heuristics,” or mental shortcuts, are often used
by decision-makers to simplify the decision process by circumventing
the use of detailed decision rules and sequential steps. According to
Gigerenzer and Goldstein (1996), if cognitive mechanisms involving fast
and frugal reasoning allow for successful reasoning in the real world, then
those mechanisms do not need to satisfy the fundamental norms and inferences
of classical rationality.
Heuristics have also provided explanations for the many systematic
biases that people tend to endorse during decision making. In large part,
Kahneman and Tversky’s (1979) research on heuristics and biases has pro-
vided a basis for uncovering the kinds of mechanisms and representations
that underlie human reasoning and decision making. Individuals tend to
simplify decision-making situations and formulate decisions based on
limited viewpoints that focus on some aspects of the decision situation
while ignoring others (Carroll & Johnson, 1990). Heuristics are typically
thought of as simple rules or strategies that are applied deliberately and
are frequently based on people’s habits, moral values, past, or stereotypic
choices (Camic, 1992). In such cases, individuals may be satisfied with
selecting the most representative behavior of the group to which they
belong (e.g., selecting a popular brand) without formally engaging in a
detailed process of decision making. Similarly, decisions can be anchored
(and hence limited) by normative factors associated with people’s supersti-
tions, commitments, or long-held beliefs (Etzioni, 1988; Gilovich,
Vallone, & Tversky, 1985).
Although much of the research on heuristics has focused on how these
mental shortcuts can mislead the decision-maker into overlooking important
information resulting in biased decisions (e.g., Kahneman, 2011), there is also
a body of work aimed at illuminating the positive contributions of heuristics.
Hertwig, Hoffrage, and the ABC Research Group (2013) have taken the posi-
tion that simple heuristics are indispensable in the social domain. They argue
that because social interactions can involve high levels of complexity, compet-
ing goals, and time pressure, there is often no alternative, but to use the simple,
approximate methods offered by heuristics. Research studies reported by this
group offer evidence that, for the most part, people are well served by simple
heuristics, such as “imitate the majority” or “trust your doctor” (e.g.,
Wegwarth & Gigerenzer, 2013). Hertwig and Hoffrage (2013) even assert
that, sometimes, heuristics can be faster and more accurate than more complex
decision-making strategies based on more complete information.
Detailed information processing can sometimes be subverted during
decision making by the presence of biases, such as framing effects. The man-
ner in which a decision problem is “framed” may also alter the way in which
a decision is approached. The framing of a problem can affect the weighting
of the different attributes of the problem. This might bias the decision-maker
to attend to selected attributes of a problem and affect the decision outcome.
Kahneman (2011) has provided descriptive examples of how people assign
differential values to situations that are framed as either gains or losses.
1.1.2 Stage-Based Models

A number of decision-making theories have focused on describing the
deliberative decision-making process in order to provide increased insight
into a person’s ability to arrive at a reasoned decision in a specific situation.
Stage-based models of decision making focus on delineating the decision-
making process in terms of fairly well-defined, sequential steps that are
followed by decision-makers to arrive at reasoned choices. Most stage-based
descriptive models of decision making emphasize the role of rational, delib-
erative processes and underscore the importance of multiple component
steps (e.g., Byrnes, 1998; Gumpel, 1994; Janis & Mann, 1977). For example,
Byrnes (1998) succinctly described decision making as involving a sequence
of four steps: (1) generation of alternative strategies, (2) evaluation of the
alternatives, (3) implementation of a strategy, and (4) learning (from conse-
quences and feedback).
Stage-based accounts have provided a useful framework for identifying
the components of effective decision making in situations where a deliber-
ative decision-making process is called for and for identifying and inter-
preting individual differences in the ability to perform each component
step. When decisions are complex, involving a number of possible conse-
quences that are difficult to anticipate or integrate, ineffective decision-
makers may focus on certain consequences to the exclusion of others, or
ignore the outcomes entirely (Byrnes, Miller, & Reynolds, 1999). Although
stage-based models typically imply that the decision-maker proceeds
through all of the steps in the specified order; Galotti (2002) questioned
whether the empirical evidence was strong enough to support a pre-
determined order for the components of the deliberative decision-making
process. Instead, she proposed the use of “phase-based” as an alternative term
to allow for variation in the order in which component steps in her model were
carried out: (1) goal setting, (2) information gathering, (3) decision structur-
ing, (4) making a final choice, and (5) evaluating the process.
More recently, the focus of the theoretical literature has been shifting
away from an emphasis on deliberative, stage- or phase-based models.
Kruglanski and Gigerenzer (2011) have pointed out that deliberative deci-
sions are not necessarily more successful than intuitive decisions. In both
cases, it depends on the match between the decision rules and the situation,
and on the processing capacity of the individual decision-maker. These
issues have been explored most thoroughly in the literature on dual-process
theories of decision making.
1.2. Dual-Process Theories

Stanovich (2010, 2011) has articulated the differential roles played by
intuition-based and reasoning-based modes of cognitive functioning in
human decision making. The intuition-based system, termed type 1 in
the generic dual-process framework proposed by Stanovich (2011), is fast,
automatic, and effortless. The reasoning-based system, type 2, is slower,
deliberately controlled and effortful. Kahneman (2011) has made a similar
distinction, but he refers to these modes of processing as system 1 and system
2. Because intuition-based thoughts are highly accessible and come to mind
quickly, some dual-process theories posit that they tend to control judg-
ments and preferences unless they are corrected or overridden by type 2 pro-
cesses (e.g., Kahneman, 2011; Stanovich, 2011). Evans (2008, 2011) has
argued that intuitive type 1 mechanisms and heuristics can operate just as
well or even better than the expectedly superior type 2-controlled
processing mechanisms, especially in complex and time-constrained
decision-making situations.
Stanovich (2010, 2011) has expanded the dual-process model into a tri-
partite model consisting of rapid, automatic type 1 processing and two levels
of slower, reasoning-based type 2 processing: algorithmic processing and
reflective processing. Processing at the algorithmic level is characterized
by the stepwise processes involved in mental tasks and the hypothetical
thinking required for generating and evaluating alternatives and their possi-
ble consequences. Processing at the reflective level involves goal processes
and cognitive style or thinking dispositions. Its key function is to interrupt
automatic, intuitive processing and put out the call for the hypothetical
reasoning activities needed to come up with a better course of action.
Stanovich (2011) reported that algorithmic processes are correlated with
intelligence, but reflective processes are not. He went on to suggest that the
continuous processing disruptions associated with ID would be most appar-
ent in the domain of algorithmic processing and the more discontinuous
processing disruptions associated with ASD would be more apparent in type
1 processing.
An interesting example of the primacy of intuition-based processing is
provided by Klein’s (1998, 2009) research on the decision making of experts
who were called upon to make important decisions on a regular basis as part
of their jobs. When Klein interviewed and observed the experts, who
included fire ground commanders, military leaders, and nurses in neonatal
intensive care units, he reported that the experts did not typically structure
a decision to search for multiple alternatives. Instead, they tended to catego-
rize a decision as an example of a prototype and then implement an appli-
cable solution based on their memory of past experiences. Klein concluded
that expert decision-makers tend to “satisfice,” employing the first solution
accessed that will work in a given situation, rather than seeking an optimal
solution. In a joint effort to explore the sources of intuition, from their dis-
parate theoretical orientations, Kahneman and Klein (2009) agreed that the
primary source of intuitive decisions is memory. Expert intuitions are based
on extensive experience in a domain, but intuitions also may arise from sim-
plifying heuristics, often resulting in inaccurate or biased decisions. Truly
expert decisions must be based on adequate experience with an environment
that affords sufficient regularity to provide valid cues.
Glockner and Witteman (2010) elaborated further on the nature of intu-
itive processes in decision making, suggesting that there are four different
types of processes underlying intuition: (1) associative intuitions—based
on simple learning and retrieval of feelings of liking or disliking or of pre-
viously successful actions; (2) matching intuitions—involving matching of
possible decision actions to learned exemplars and prototypes; (3) accumu-
lative intuitions—based on quick, automatic processes involving integration
of memory traces with currently available information; and (4) constructive
intuitions—the automatic construction of consistent representations based
on integration of memory traces with currently available information.
Glockner and Witteman suggested that future research should focus on
understanding these underlying processes rather than continuing the debate
on whether intuitive or deliberative processes result in the best decisions.
New research is also beginning to shed light on the relation between type
1 and type 2 processing and whether and to what extent the two processes
operate sequentially/serially or simultaneously during decision making.
As an alternative to standard, dual-process theories, Reyna and Brainerd

(2011) have proposed “fuzzy trace” theory. It is based on their identification
of five processing components in decision making: (1) stored knowledge and
culturally transmitted values, (2) mental representations of situations, (3)
retrieval of knowledge/values, (4) implementation of knowledge/values,
and (5) developmental and individual differences in monitoring and
inhibiting interference. According to fuzzy trace theory, there are two types
of mental representation that can be retrieved in parallel. The first type, ver-
batim representation, provides the precise information needed for analytic,
deliberative processing. The second type, gist representation (which often
incorporates emotion), is associated with the fuzzy, impressionistic processes
of intuition. The theory posits that most adults prefer the simplest available
gist representation that will allow them to make a decision. Their research
suggests that intuitive, gist-based processes seem to foster effective decision
making in experts and older adults. However, they note that individuals with
ASD are more likely to favor detailed verbatim representation, which may
explain why they are less prone to framing effects and other biases associated
with gist-based processing.
1.3. Role of Noncognitive Processes in Decision Making

Recent thinking reflects a broad view of the processes involved in decision
making (e.g., Kahneman, 2011; Reyna & Brainerd, 2011). Theoretical
treatments of the nature of decision making have emphasized the inter-
dependency of cognitive, motivational, emotional, and contextual factors
in decision making and the need to view these underlying factors in an inte-
grated manner. According to Kuhl (1986), cognition, motivation, and emo-
tion each operate as separate information-processing subsystems to perform
unique functions in the process of decision making. At various stages of the
decision-making process, the three subsystems interact with each other in a
variety of ways to determine decision outcomes. Although, thus far in this
chapter, we have focused on cognitive aspects of decision making, a growing
body of research has provided evidence of the varied and integral roles of
motivation and emotion in decision making.
1.3.1 Motivation
Fiske (1992), Kruglanski (1989), and Shah and Kruglanski (2000) have
argued that cognition and motivation constitute two important components
of decision making that interact with each other to produce different
types, or degrees, of motivational input that affect the extent and direction
of information processing. In the context of decision making, motivation

pertains to both goal-related processes and to a person’s self-beliefs about
her/his capabilities as they relate to the extent to which a goal is attainable
and worth pursuing. Decision theorists have drawn upon Bandura’s (1977,
1997) self-efficacy theory to illustrate how cognitions are influenced by
individual perceptions of control and the decision-maker’s feelings of
agency about their ability to carry out a particular action. Attribution theory
(Weiner, 1986), self-efficacy theory (Bandura, 1977, 1997), and other
related theories have proposed that cognitions relevant to choosing a partic-
ular course of action during decision making are influenced by individual
perceptions of efficacy or control. The development of efficacious self-
beliefs effects changes in the motivational states and behavioral intentions
of individuals that eventually impact individual decision-making styles
and outcomes. It is likely that an individual’s decision-making style is
also influenced by her or his cultural background, values, and ethics
(Adler, 1991; Brake, Walker, & Walker, 1995).
Decision making is guided not simply by a search for an accurate, logical,
or rational solution but also by the motivation to arrive at particular, person-
ally desirable outcomes. Decision-making processes are presumed to be
influenced by environmental factors associated with the personal histories
of individuals and the cultural context within which an individual operates
as a decision-maker. Experiences are interpreted and assimilated on the basis
of generalized cultural schemata, consisting of broad sets of cultural values
and norms, derived from past interactions and belief systems. The
decision-making parameters do not remain static across multiple decision-
making contexts. Rather, they change as a function of shifting goals and
priorities.
People’s reasoning is guided by their goals and environmental con-
straints. Byrnes (1998) defined decision making as the process of choosing
a course of action from among two or more alternatives while in the pursuit
of one’s goals. The goals or values reflected in choices, once acquired or
internalized, may be culture-specific (e.g., collectivist vs. individualistic
goals) and sensitive to situational and contextual factors linked to the
decision-making situation. People are motivated by more than one goal
and often experience conflicting pressures or motivations for and against cer-
tain goals. The impact of competing goals is dependent on their relative
strength and ease of attainment. How we balance our goals and how we elect
to pursue them depend on their motivational content, with certain types of
goals receiving preference as specific needs arise (Higgins, 1997; Kruglanski,
1996). In addition, the manner wherein specific goals are pursued can vary
considerably across individuals and situations. In effect, the goals provide the
constraints within which various motivational and personal characteristics
may express themselves to inform the identification and evaluation of deci-
sion alternatives.
1.3.2 Emotion
Decision making, especially in social situations, cannot be understood with-
out considering emotional and contextual variables (Argyle, 1991; De
Martino, Kumaran, Seymour, & Dolan, 2006; Parkinson & Simons,
2009). Recent advances in the neuroscience of affect and emotion have con-
tributed substantially to our growing understanding of the neural basis of
decision making (Delgado, Phelps, & Robbins, 2011). For example, the
neuroscience of social decision making has begun to yield important insights
about the neural mechanisms that support decisions about trust and confor-
mity to social norms (Rilling & Sanfey, 2011).
Neuropsychologists have studied the impact of relationships between
emotional control and reasoning capacities in relation to people’s ability
to resolve everyday problems (e.g., Frith & Singer, 2008; Rath, Simon,
Langenbahn, Sherr, & Diller, 2003). It is assumed that the initial,
problem-orientation phase of decision making is primarily affective in
nature. In situations that call for decision making under uncertainty, the
integration of emotional contextual information into the process can serve
as a useful heuristic. Some theorists have viewed the role of emotion in
decision making as largely negative (e.g., De Martino et al., 2006;
Martin & Delgado, 2011). Others, however, have challenged this assump-
tion and suggested that intuitive/emotion-based decisions may
“incorporate important social insights” (Frith & Singer, 2008, p. 3884).
Frith and Singer pointed out that effective social decision making relies
on understanding the emotions and intentions of others and is aided by
the mirror system, empathy, and “theory of mind”. Frijda (1986) has
affirmed the valuable input of emotions in helping decision-makers to pri-
oritize goals and in generating a state of action readiness needed to respond
to relevant concerns in a particular situation. This shift in emphasis that
acknowledges the central role of emotions in decision making has been ter-
med the “emotion revolution” by Weber and Johnson (2009). They pro-
posed that emotional, or affective, processes, described as automatic or
effort-free, can serve the following four functions in decision making:
(1) spotlighting key information, (2) providing new information, (3) serv-
ing as a common currency, and (4) serving as a motivator.
An extensive and growing body of research has examined the effects of
emotions and affect specifically on information processing and decision
making (for reviews, see Clore, Schwarz, & Conway, 1994; Delgado
et al., 2011; Eagly & Chaiken, 1993; Epstein, 1994; Fiedler, 2000; Isen &
Geva, 1987; Lazarus, 1999; Martin, 2000; Zajonc, 1980). Studies on affect
and emotions have emphasized that emotional appraisals may affect the
degree to which people engage in systematic versus heuristic or intuitive
processing. Variations in information processing may be explained in terms
of differences in individual emotional appraisals (e.g., happiness or sadness)
of decision-making situations (Keltner, Ellsworth, & Edwards, 1993;
Tiedens & Linton, 2001). Recent research has emphasized the necessity
of examining differences in processing based on more diverse sets of emo-
tions, within positive and negative affective states. For example, studies (e.g.,
Bodenhausen, Kramer, & Susser, 1994; Lerner, Goldberg, & Tetlock, 1998)
have shown that although feelings of sadness promote systematic processing,
anger fosters more heuristic processing.
The effectiveness of decision making may decline in situations of high
stress, anxiety, or emotion ( Janis & Mann, 1977; Keinan, 1987). Other
effects on the choice of decision strategies may come from people’s emo-
tional reactions to the decisions they make. For example, once a decision
has been made in a particular situation, the decision-maker may consider
what would have happened if she/he had chosen differently. This would
lead her/him to experience certain emotions (e.g., joy or regret), which,
in turn, may affect her/his response to other decision tasks. It is rational
and adaptive to account for emotional reactions and assume that the expe-
rience will inform individual decision-making routines in the future.
Schwarz and Clore (1996) mentioned that self-regulatory focus serves as a
moderating factor in interpreting and internalizing emotions associated with
past experiences. For example, in the event that goals are not met, individ-
uals who are promotion-focused may perceive failure as the absence of a
desired outcome and hence feel dejection or disappointment. In contrast,
prevention-focused individuals may view the failure as the presence of
unwanted outcomes, reacting in an agitated or threatening manner. Such
distinctive emotional reactions tied to regulatory mechanisms are assumed
to serve as information signals and impact the individual’s encounter
with the decision-making situation. Several studies (e.g., Kalisch, Wiech,
Herrmann, & Dolan, 2006; Ochsner & Gross, 2005) have shown that
employing emotional regulatory strategies can reduce the intensity of a sub-

jective feeling or emotion (negative and positive) and allow for a more con-
trolled response to an emotionally charged decision-making situation.
Personality traits such as sensation seeking, impulsivity, and dogmatism
(Byrnes, 1998, Miller & Byrnes, 1997) have been observed to impact the
rigor of information processing and the ability to predict the consequences
of alternative choice options.
1.4. Developmental Perspectives on Decision Making

There is mounting evidence to suggest that profound changes, beginning
early and continuing into the late adolescent years, occur in functions relat-
ing to emotion regulation, response inhibition, and calibration of risk-
reward. Research findings (see Reyna & Farley, 2006; Rivers, Reyna, &
Mills, 2008) have supported the view that the cognitive processing of adults
and adolescents in evaluating risks associated with dangerous behaviors or in
estimating the seriousness of the consequences of risky behaviors is fairly
similar. Rather, it appears that the age-based differences in risk processing
are related to more complex social, emotional, and self-regulatory factors
dominant during the adolescent period. Albert and Steinberg (2011) have
linked social and emotional influences in adolescence to changes in core
motivational processes, such as sensation seeking and heightened sensitivity
to immediate rewards, as well as age-related influence of contextual variables
(e.g., presence of peers, social expectations) on risk-taking behavior.
Loewenstein, Weber, Hsee, and Welch (2001) have ascribed an adolescent’s
cognitive assessment of the expected value or desirability of a risky choice to
her/his anticipated emotional outcomes tied to the risky behavior. For
instance, adolescents may need to manage competing expected emotional
consequences (e.g., lessening social anxiety by focusing on feelings of peer
belongingness vs. increasing social anxiety by focusing on feelings of exclu-
sion) when making a risky decision. Adolescents’ engagement in risk taking
has been found to be mediated by the degree to which they anticipate a pos-
itive feeling tied to immediate reward seeking during risk taking (Romer &
Hennessy, 2007; Steinberg et al., 2009). Research studies (e.g., Cauffman
et al., 2010, Crone & Van der Molen, 2007) also show that the preference
for immediate rewards declines developmentally and the capacity to antic-
ipate and learn from negative consequences and adjust decision-making
behaviors accordingly (i.e., avoid choices that may yield immediate gains
but result in long-term losses) increases with maturation.
Pertinent to this overall understanding of decision making and risk

taking during this period are the widespread observations that adolescents’
experience of arousal, motivation, and emotion (an impact of puberty-
related maturation) develops before their ability to regulate these feelings
(e.g., Casey, Hare, & Galvan, 2011). This disjunction between adolescents’
affective experiences and the development of regulatory competence is a
contributing factor to their risky or impulsive behaviors. At times, they
may find themselves in situations where their affect urges them to go
forward in embracing newer, perhaps sensational, opportunities when
they may not be fully equipped to handle the new opportunities without
risking harm. Martin et al. (2002) found a significant correlation between
puberty maturation and sensation seeking and risk taking in a large group of
young adolescents (ages 11–14 years), but there was no significant corre-
lation between chronological age and sensation-seeking and risk-taking
behaviors.
In a dual systems model of adolescent risk taking, Steinberg (2010)
has identified two distinct systems that interact during adolescence: a cog-
nitive control system and a socio-emotional system. The cognitive control
system influences long-term planning and the ability to inhibit impulsive
behavior and develops gradually over a longer period of time. However,
the socio-emotional system responsible for reward seeking and sensation
seeking asserts itself and peaks abruptly during adolescence. The differing
time tables, with the socio-emotional system being highly developed when
the cognitive control system is not yet sufficiently developed to control
the impulses of the socio-emotional system, make adolescence, especially
midadolescence, a time of heightened vulnerability to risky and reckless
behaviors. Paralleling Stanovich’s (2011) conception of two types of think-
ing (automatic and intuitive type 1 processing or deliberative and effortful
type 2 processing), it appears that type 2 thinking, akin to the cognitive
control system functions, may develop later in adolescence. On the other
hand, type 1 thinking, analogous to the socio-emotional system functions
that generate more impulsive and “acting-without-thinking” behavior,
may dominate decision-making behavior during early adolescence. It has
also been observed that the effects of peer influence on decision making
are heightened during adolescence (e.g., Clark & Loheac, 2007;
Monahan, Steinberg, & Cauffman, 2009). In one study, the presence of
peers doubled the amount of risk taking engaged in by adolescents
(Gardner & Steinberg, 2005). In another study, adolescents who believed
that a peer was observing them chose to take more risks on a gambling task
than adolescents who believed that they were playing alone (Smith,
Chein, & Steinberg, 2014). Neuroimaging studies have associated the
effects of peer influence with heightened activity in the areas of the brain
that reflect the valuation of rewards (Chein, Albert, O’Brien, Uckert, &
Steinberg, 2010).
Advances in developmental neuroscience (see Casey, Giedd, & Thomas,
2000; Keating, 2004; Spear, 2000) have pointed to sizeable changes in both
the structure and functional aspects of brain development throughout the
course of adolescence. Specific changes are observed in multiple regions
of the prefrontal cortex with rapidly expanding linkages to the whole brain
leading to enhanced connectivity and communication among different brain
regions. These changes support improvements in various aspects of execu-
tive functioning, including metacognition, long-term planning, self-
regulation, and the coordination of affect and cognition, resulting in
increases in adolescents’ efficiency of information processing and reasoning.
Martin et al. (2002) and Spear (2000) have also highlighted that there is
improved connectivity between regions of the prefrontal cortex and several
areas of the limbic system during adolescence, a restructuring that further
shapes the ways in which individuals evaluate and respond to risk and
reward. Steinberg et al. (2009) have demonstrated that future-orientation
variables such as planning ahead and anticipation of long-term consequences
are embraced in the cognitive control system and they mature gradually
from younger adolescence to adulthood. Whatever the underlying pro-
cesses, there is broad consensus that older adolescents show perceptible
improvements in deductive reasoning and enhanced efficiency and capacity
for information processing (Wigfield, Byrnes, & Eccles, 2006). As a result of
these gains, the core of the change is expressed in adolescents eventually
becoming more self-regulated and self-directed.
1.5. Summary of Theoretical Perspectives on Decision Making

The above review of existing theories and developmental perspectives on
decision making articulates the patterns, processes, and variations in
decision-making behavior that have been considered within the typical
range of human functioning. This overview was included to provide the
basis for a comparative view of the decision-making capacities and pro-
cesses utilized by individuals who are discrepant from the norm as a result
of their disability, such as individuals with IDD, the focus group in this
chapter.
The theories reviewed above provide a backdrop for examining the

nature of decision-making difficulties likely to be encountered by individ-
uals with IDD. The descriptive theories acknowledge that decision making
is constrained by the capacity limits of an individual and that heuristics are
often used to simplify the decision-making process. This makes the study of
the role of information-processing limitations in the decision making of
individuals with IDD essential. Dual process theories that suggest a distinc-
tion between intuitive and reasoning-based modes of decision making raise
the possibility that each of these modes may be affected differentially in indi-
viduals with different types of IDDs. Of particular importance are the the-
oretical explications of the complex and intertwined roles of cognitive and
noncognitive processes (e.g., motivation and emotion) in decision making.
Although the decision-making theories described above were not based
upon research with individuals with IDD, the in-depth analysis of decision
making provided by these theories highlights key processes as possible loci of
the decision-making difficulties observed in individuals with IDD.
Although adults without disabilities often arrive at effective decisions with-
out applying a deliberative, stepwise process, this may not be the case for indi-
viduals with IDD. In addition, the types of approaches needed to promote
effective decision making may vary with the type of decision-making situa-
tion. Decision making in interpersonal situations where there is a risk of coer-
cion or abuse, as has been the primary focus of our research, is distinct from
decision making in other domains (e.g., vocational or lifestyle choices) in that
the decision-making process in these interpersonal situations is essentially a
noniterative process with minimal scope for correction within the course
of decision making. In Section 2, research studies with individuals with var-
ious forms of IDD are examined in light of these theories in an effort to iden-
tify disability-specific sources of decision-making difficulty.
2. DECISION MAKING AND IDD

Thus far in this chapter, we have been using the term IDD in its most
inclusive sense to include individuals with ID or ASDs or both because we
believe that many individuals who fall within the broad IDD category will
experience difficulties with decision making, especially in situations with a
risk of victimization. In the remainder of the chapter, however, we will use
more specific terms, wherever possible, to describe the participants of indi-
vidual research studies so that any implications for differentiated interven-
tion strategies will be apparent. All of the conditions referred to as IDD
involve cognitive and/or social limitations that may affect either decision-
making competence or style. However, within the broad IDD category,
disability-specific characteristics associated with specific conditions may
affect decision making in particular ways.
The American Association on Intellectual and Developmental Disabilities
(American Association on Intellectual and Developmental Disabilities, 2010)
defines ID as a condition “characterized by significant limitations both in
intellectual functioning and in adaptive behavior as expressed in conceptual,
social, and practical adaptive skills.” Although ID is itself a global term
encompassing a range of conditions with known and unknown etiologies,
most of the existing research on decision making has focused on identifying
and remediating difficulties in heterogeneous ID samples in response to
alarming statistics on the social vulnerability of this diverse group. Research
studies linking disability-specific patterns of decision making to specific disor-
ders associated with ID, such as WS, remain scarce, although evidence is
emerging regarding the specific vulnerabilities of individuals with singular
types of ID (Fisher, Moskowitz, & Hodapp, 2013).
According to the most recent DSM-V diagnostic criteria (American
Psychiatric Association, 2013), ASD is defined as consisting of persistent
deficits in social communication and social interaction accompanied by
restricted, repetitive patterns of behavior that emerge during the early devel-
opmental period. Levels of social anxiety are often high in individuals with
ASD, typically exceeding levels in the general populations (e.g., Lecavalier,
Gadow, DeVincent, Houts, & Edwards, 2009; White & Roberson-Nay,
2009). Studies investigating decision making in individuals with ASD have
begun to yield important information about their decision-making patterns.
In the following sections, available research on decision making in indi-
viduals with ID, WS, and ASD will be discussed in turn.
2.1. Research on Decision Making with Individuals with ID

Early research with individuals with ID suggested serious shortcomings in
their decision-making effectiveness. Most of the studies viewed decision
making from the perspective of stage-based models, within which people
with ID typically failed to apply a systematic decision-making process,
but rather appeared to rely on a limited number of solutions drawn from
their past experience that they applied to new situations in a rote manner.
Although these decisions may have involved some sort of intuitive
processing, they were not typically reported to have been effective decisions.
In addition, when people with ID were instructed to apply a multistep pro-

cess, they tended to experience limited success at each stage of the process,
showing incomplete comprehension of decision situations, generating few
alternative solutions, failing to anticipate possible negative consequences,
and not selecting an appropriate course of action (Castles & Glass, 1986;
Healey & Masterpasqua, 1992; Jenkinson & Nelms, 1994; Smith, 1986;
Tymchuk, Yokota, & Rahbar, 1990; Wehmeyer & Kelchner, 1994; see
Hickson & Khemka, 1999, for a detailed review of these early studies).
Given that ID is characterized by significant limitations in the “cognitive”
functioning of the individual, the disability is broadly associated with differ-
ences in thought processes, reasoning, memory, and comprehension. The
social adaptive behavior deficits intrinsic to ID are also associated with diffi-
culties with social problem solving, credulity (i.e., lack of wariness), and
extreme gullibility (Greenspan, Loughlin, & Black, 2001). These factors
can potentially confound the motivational regulation of individuals with
ID during decision making, extending beyond the cognitive dimension.
Additionally, as discussed by Stanovich (2011) and Hickson and Khemka
(2013), the hypothetical thinking needed to play out the possible conse-
quences of alternative courses of action is an important step in the
decision-making process with high demands on verbal fluency, memory,
abstract thinking, and overall information-processing capacity, all areas of dif-
ficulty for individuals with ID.
The evaluation of consequences involves predicting immediate and
long-term consequences of a particular action. Research on the ability of
people with ID to perform temporal discounting tasks (e.g., Willner,
Bailey, Parry, & Dymond, 2010) suggests difficulties with forecasting
delayed rewards and a greater tendency for impulsive decision making in
favor of short-term gains. Although temporal discounting has been studied
largely in the context of monetary/rewards-based decision-making tasks for
individuals with ID, the patterns of interference of the temporal dimension
in decision making are likely to prevail across different domains of decision
making, especially in situations involving risky interpersonal decisions
where long-term gains (or losses) may need to be weighed against immediate
gains. For instance, individuals with ID may engage in risky decision making
by choosing behaviors that are high in immediate subjective desirability or
excitement, but that may carry the potential for injury or loss.
Our own initial study (Hickson et al., 1998) on the decision-making
effectiveness of adults with mild and moderate ID provided evidence of their
decision-making difficulties relative to the performance of adults without
disabilities. Study participants with and without ID responded to vignettes

depicting situations in which a protagonist was faced with a decision involv-
ing the possibility of interpersonal conflict, physical harm, or sexual assault.
Participants were asked what the protagonist should do and why. Overall,
adults without disabilities gave effective decision responses (i.e., responses
that appeared to be in the best interest of the protagonist) about 91% of
the time, while adults with ID gave effective decision responses only about
50% of the time.
In another study (Khemka & Hickson, 2000), we investigated the ability
of women and men with mild to moderate ID to suggest prevention-focused
decisions in response to simulated video situations representing physical,
sexual, or verbal abuse. Overall, the participants suggested independent,
prevention-focused decisions aimed at resisting or stopping the abuse 45%
of the time and other-dependent, prevention-focused decisions that con-
sisted of seeking support or help from someone nearby, an additional
20% of the time. Early efforts to improve the decision-making effectiveness
of individuals with ID reported only limited success (see Hickson &
Khemka, 1999, for a review of these studies). Most approaches used to teach
individuals with ID to handle interpersonal problems and decisions used a
stage-based model, but did not address the complete constellation of com-
ponents. Some studies monitored the number of steps identified and/or
applied, but more typically the studies focused on a single step in the process,
usually the generation of alternatives (e.g., Vaughn, Ridley, & Cox, 1983).
Only two studies employed actual decision-making training tasks (Ross &
Ross, 1978; Tymchuk, Andron, & Rahbar, 1988). Although these interven-
tion studies were generally successful at teaching the participants to apply the
steps to solving problems, generalization was limited and the studies focused
narrowly on cognitive processes.
More recently, we have conducted a series of studies aimed at assessing the
effectiveness of interventions designed to provide adults with ID with tools to
make effective self-protective decisions in situations of abuse. The handling of
abuse situations typically requires a degree of deliberative decision making to
identify the situation as abusive and to generate and evaluate possible alterna-
tive decision actions in terms of their potential for stopping the abuse. In the
first study in this series, Khemka (2000) developed and evaluated the effective-
ness of an intervention designed to teach a decision-making strategy, increase
self-awareness of personal safety goals and values, and induce resilient self-
beliefs of decision-making efficacy in order to encourage effective decision
making in situations of abuse by women with ID.
The study compared two training approaches with a control condition:

(1) a traditional cognitive decision-making training approach, (2) an inte-
grated cognitive and motivational decision-making training approach, with
added emphasis on increasing personal agency beliefs and adoption of goals
emphasizing safety and independent action, and (3) no training. Thirty-six
women with mild to moderate ID were randomly assigned to one of the
three groups. The dependent variable of primary interest was effective, inde-
pendent, self-protective decision-making responses to a set of video
vignettes in which a protagonist was faced with situations involving physical,
sexual, or verbal abuse. Although both training approaches were effective
relative to the control condition, the approach that addressed both cognitive
and motivational aspects of decision making was superior to that addressing
only the cognitive aspects of decision making. The findings of the study
suggested that in order to improve the quality of decision responses, it is nec-
essary to augment cognitive training with training that addresses the moti-
vational aspects of decision making, including personal agency beliefs and
goal selection.
In a second study, building upon Khemka’s (2000) findings, we devel-
oped and evaluated the Effective Strategy-Based Curriculum for Abuse Prevention
and Empowerment (ESCAPE) (Khemka & Hickson, 2008) with 36 women
with mild and moderate ID (Khemka, Hickson, & Reynolds, 2005). The
purpose of the curriculum was to empower the women to become effective
decision-makers able to engage in healthy relationships and to protect them-
selves against violence and abuse. The ESCAPE curriculum consists of
12 instructional lessons (Units 1 and 2) and six support group sessions
(Unit 3) designed for small group instruction with an instructor/facilitator.
Unit 1 is designed to build a knowledge base consisting of key concepts of
abuse as a basis for identifying abuse situations that might require a deliber-
ative decision-making process. The focus of Unit 2 is to establish priority
goals (i.e., safety and independent action) and to teach and provide guided
practice in applying a four-step decision-making strategy to hypothetical
situations involving abuse. Unit 3 consists of support group sessions in
which participants have opportunities to apply the decision-making strategy
to situations in their own lives. In accord with dual-process theory, partic-
ipants are encouraged to apply spontaneous, intuitive (type 1) approaches
in situations that do not involve abuse. However, in problem situations that
do involve abuse, participants are taught to systematically apply a delibera-
tive, self-protective decision-making strategy by answering the following
questions: (1) Is there a problem (involving abuse)? (2) What are my choices
(alternative ways to handle the problem)? (3) What could happen if. . . (for
each alternative)? and (4) What is the best thing for (name of protagonist) to
do in this situation? As can be seen, this approach addresses when and how to
apply a systematic type 2 approach involving hypothetical, algorithmic
processing to consider possible alternatives and their potential consequences,
and which, according to Stanovich (2011), is the ability most likely to be
impaired in individuals with ID. The results of the evaluation study indi-
cated that the 18 women in the intervention group obtained significantly
higher posttest scores than the 18 women in the randomly assigned control
group on the key criterion measure of independent, prevention-focused
decision making in situations of abuse.
The original ESCAPE curriculum was subsequently modified so that it
would be appropriate for teaching self-protective decision-making strategies
to men as well as women. The efficacy of this revised, ESCAPE-DD
(Khemka & Hickson, 2008), version of the curriculum was evaluated in a
recent study involving 58 adults with mild and moderate ID (Hickson,
Khemka, Golden, & Chatzistyli, 2012). Participants were randomly assigned
to either an intervention group, who received ESCAPE-DD, or to a wait-list
control group, which was given delayed access to the curriculum upon com-
pletion of posttesting. Subjects completed individual pretests and posttests
consisting of six vignettes depicting situations involving sexual, physical,
and verbal abuse. After each vignette was read to them, subjects were asked
to respond to one comprehension question (What is happening in this story?) and
one decision-making question (What should (name of protagonist) do?).
Results indicated that, on the posttest, subjects in the intervention group
produced significantly more comprehension responses that accurately iden-
tified situations as involving abuse or violation than subjects did in the con-
trol group. Subjects in the intervention group also produced significantly
more effective decision-making responses reflecting attempts to avoid or
escape from the abuse than subjects did in the control group. Overall,
approximately 84% of the intervention group’s posttest responses consti-
tuted reasonable attempts to avoid or escape from the abuse situation, while
only 63% of the control group’s posttest responses represented such
attempts. When responses to the decision-making questions were catego-
rized further to look at responses that indicated an effort to be safe now by
verbally resisting, physically fleeing, or calling for immediate help to avoid
or escape from the threatened or ongoing abuse, a significant difference
favoring the intervention group was found. This finding suggested that
adults who participated in the intervention were producing more responses
with the potential to actually stop the abuse from happening than were the
adults in the control group.
A significant positive correlation was found in this study between
effective decision-making scores and IQ. Correlational analyses were also
conducted to examine relationships between posttest safe-now decision-
making scores and mastery of each of the four decision-making strategy
components measured during the final training session. A significant positive
correlation was obtained for only the third step—evaluation of possible con-
sequences. Interestingly, mastery levels were the lowest for this step, with
only 70% of the sample reaching mastery. Mastery levels for the other three
steps (problem identification, generation of alternatives, and selection of a
decision action) ranged between 80% and 90% and correlations with safe-
now posttest responses were low and not significant. It is important to note
that evaluation of consequences is the component of decision making that
relies most heavily on extensive hypothetical thinking and is, as suggested by
Stanovich (2011), most likely to be affected by the cognitive limitations of
individuals with ID.
Given the importance of peer group influences on adolescent social
interactions and hence their interpersonal decision-making skills (e.g.,
Gardner & Steinberg, 2005), our recent work with adolescents has empha-
sized the study of decision making in the context of peer pressure. Most
studies in the developmental literature have focused on the negative effects
of peer influence during adolescence in terms of risky behaviors or peer vic-
timization. Only a few researchers have acknowledged the impact of neutral
or positive peer pressure (Barry & Wentzel, 2006; Ellis & Zarbatany, 2007;
Steinberg & Silverberg, 1986). In our research, we have chosen to take a
broad view of peer influence that includes both positive and negative peer
pressure, with the goal of not only preventing risky decision making but also
fostering age-appropriate prosocial interactions and positive personal rela-
tionships. As Mounts and Steinberg (1995) have pointed out, norms and
values may vary across adolescent peer groups, and sometimes the influence
of peers can be adaptive, encouraging socially desirable behavior (e.g., pos-
itive peer pressure to do well in school, avoid drugs, not rush into sexual
relationships). Accordingly, in the decision-making scenarios used in our
adolescent studies (e.g., Khemka, Hickson, Zealand, & Mallory, 2011;
Khemka, Hickson, Mallory, & Zealand, 2013), we have attributed motives
to peers that manifest in a positive or prosocial manner (e.g., encouraging
peer to finish homework before going out) as well as motives that are clearly
negative (e.g., pressuring peer to use drugs).
In an initial intervention study, we developed and evaluated a six-session

intervention, Peers Engaged in Effective Relationships: A Decision-Making
Approach (PEER-DM), to provide adolescents with a strategy for handling
situations involving peer pressure (Khemka et al., 2011). The lessons of
PEER-DM are designed to teach the concepts of positive and negative peer
pressure, to establish goal priorities, and to increase feelings of self-agency as
a basis for recognizing situations of negative peer pressure where deliberative
(type 2) processing may be needed to handle the situation effectively. Par-
ticipants are then provided with instruction and guided practice with a four-
step decision-making strategy that provides a schema for handling problem
situations involving negative peer pressure, including bullying. According to
this four-step strategy, once the problem has been identified as one involving
negative peer pressure (Step 1), the decision-maker is instructed to proceed
in a deliberate way to generate possible options for how to handle the sit-
uation (Step 2). Possible consequences of each hypothetical option are then
considered and weighed against previously established goals (e.g., safety and
not getting into trouble) (Step 3). The evaluation of hypothetical alternatives
and their possible consequences leads to the selection of the final decision
action (Step 4). A visual decision-making chart is provided to scaffold the
hypothetical processing required in the generation and evaluation of possible
alternatives.
The findings of a randomized experimental study with 28 adolescents
with ID, ASD, and other developmental disabilities (e.g., multiple disabil-
ities, other health impaired) support the effectiveness of the PEER-DM
intervention (Khemka et al., 2011). The group that received instruction
(n ¼ 13) in the use of a decision-making strategy was more likely than a
wait-list control group (n ¼ 15) to produce effective decision-making
responses involving active attempts to resist negative pressure from peers,
by negotiation, direct refusal, or reporting.
Taken as a whole, this series of studies suggests that the decision making
of adolescents and adults with ID is constrained by limitations associated
with comprehension, reasoning ability, and overall processing capacity.
2.2. Research on Decision Making with Individuals with

WS—A Singular Disorder Associated with ID
Over the past two decades, an impressive body of research has accumulated on
the implications of specific genotypes and phenotypes of singular conditions
associated with ID for performance on a wide array of tasks. Although clear
and comprehensive knowledge has become available about many of these
conditions, including WS, Down syndrome, and Fragile X syndrome, we

were unable to find studies that have focused on the impact of these specific
disorders on decision-making performance. As a first step, we report some
preliminary findings on decision making in individuals with WS.
Most individuals with WS have overall IQs in the borderline to moder-
ate ID range with dominant socio-communicative language difficulties (e.g.,
low conceptual/relational language and pragmatic skills). In comparison to
other developmental disabilities, individuals with WS exhibit a distinct
social-emotional and behavioral profile that appears to be a consistent phe-
notypic feature of this disorder (Dykens, 2003). They have been described as
being overly friendly, prone to indiscriminately approaching strangers, and
highly empathetic in their social interactions. Despite the fact that individ-
uals with WS may appear to have a fearless social personality, they exhibit
many fears and anxieties (Dykens, 2003). They typically show substantial
problems in social adjustment, and in forming and sustaining friendships.
Individuals with WS also lack social judgment and experience sensory,
anxiety and attention problems (see Doyle, Bellugi, Kronerberg, &
Graham, 2004; Järvinen-Pasley et al., 2008; Leyfer, Woodruff-Borden,
Klein-Tasman, Fricke, & Mervis, 2006; Mervis & John, 2010; Tager-
Flusberg & Sullivan, 2000). The motivational inputs in decision making
for individuals with WS are likely to be driven by their eagerness for social
interaction resulting in increased risk taking and risky decision making and
enhanced vulnerability to victimization.
In an exploratory study by Hickson, Khemka, Collado, Spillane, and
Wang (2004), we conducted a series of assessments with a group of
12 young-adult women with WS and mild ID as a basis for adapting the
ESCAPE curriculum to meet their needs. Because women with WS tend
to be trusting, gullible, and eager for social interaction, they are at particular
risk for victimization and abuse. This project represented an effort to gather
information as a basis for tailoring the ESCAPE curriculum so that it could
provide women with WS with an effective repertoire of self-protective
decision-making skills. Adaptations were based upon several rounds of
videotaped instructional sessions with ESCAPE involving small groups of
women and an instructor. Observations of the sessions and interviews with
the instructors suggested several issues and concerns that provided the basis
for curriculum modifications that were incorporated into an adapted version
of the curriculum called ESCAPE-WS. Key concerns included difficulty
comprehending and applying the safety and independence goals as well as
some confusion and difficulty applying the decision-making strategy itself.
Additional concerns included inconsistent attention and engagement as well

as visuospatial problems with the wall charts. To address the comprehension
issues pertaining to the application of the goals and strategy, the number of
goals was reduced and a strategy step was added to make the goal-checking
process more explicit. Formal turn-taking procedures were instituted to
increase attention and engagement and individual worksheets replaced wall
charts in order to address the visuospatial problems.
The five women who received the adapted curriculum during the final
phase of the study increased their rate of effective decision-making responses
from 50% to 77% on a pretest/posttest measure of decision making, in spite
of the fact that they were able to complete only nine of the 12 ESCAPE-WS
lessons prior to the end of the school year.
Although the design of this exploratory/descriptive study did not allow
for a control group, which precluded clear interpretations about curriculum
effectiveness, the identified concerns did suggest some key factors con-
straining the decision-making effectiveness of women with WS. The
women appeared to have a positive response to our attempts to address these
factors, which included comprehension, attention, and the motivational
goal-related processes of self-protective decision making, supporting the
desirability of calibrating interventions to the phenotypic profiles of individ-
uals with singular types of ID.
2.3. Research on Decision Making with Individuals with ASD

Although systematic research on how the characteristic features associated
with ASD influence decision-making behavior is limited, evidence of the
predispositions to optimal (and nonoptimal) decision making of individuals
with ASD is emerging. A number of research studies involving risk-taking,
reward-processing, or gambling decision-making tasks have been conducted
that offer insight into the possible difficulties for individuals with ASD in
everyday decision making, especially social situations that require integrated
cognitive and emotional processing.
Most research studies have involved participants whose IQs fall in the
average or above average range, focusing on participants with Asperger syn-
drome or high-functioning autism (e.g., Bernard-Opitz, Srira, & Nakhoda-
Sapuan, 2001; Hillier, Fish, Cloppert, & Beversdorf, 2007). Although these
studies have addressed a broad range of social skills that sometimes have
included aspects of decision making, they have often used the term social
skills imprecisely, making it difficult to draw clear conclusions from this
body of work (e.g., Boujarwah, Hong, Arriaga, Abowd, & Isbell, 2010).
One study that included some participants whose cognitive levels were
comparable to those of the ID samples discussed in previous sections
(Verbal IQ ¼ 57–101) suggested that the generation of alternatives may be
an area of particular difficulty for individuals with ASD because of their
well-documented issues with flexibility. The authors of this study, Ruble,
Willis, and Crabtree (2008), reported that more than half of their participants
improved in their ability to generate multiple solutions to problems after
participation in a cognitive/behavioral social skills group.
In an often-cited study by De Martino, Harrison, Knafo, Bird, and Dolan
(2008), young adults with ASD (Mean IQ ¼ 112.1) showed significantly less
sensitivity to a contextual-framing effect (financial tasks presented in either a
gain or a loss frame) in a decision task and revealed a more logical pattern of
decision making, in comparison to age- and IQ-matched young adults with
typical development. Although the pattern of decision making for the indi-
viduals with ASD demonstrated logical consistency, it implied reduced
behavioral flexibility and difficulty with incorporating emotional cues into
the decision process. Psycho-physiological evidence collected in this study
(skin conductance response measuring emotional sensitivity) corroborated
evidence from previous studies by De Martino et al. (2006) and
Kahneman and Frederick (2007). It pointed toward a potential core neuro-
biological deficit in ASD that interfered with the ability to integrate emo-
tional context easily into the decision-making process. This deficit is
noted to assume considerable importance during social interactions
in situations of uncertainty when information about others is often ambig-
uous and the need to absorb emotional contextual information into the deci-
sion process outweighs the need for standard inferential reasoning processes.
For optimal decision making in uncertain social environments, the ability to
incorporate a broad range of contextual cues into the decision process is
interpreted to operate as an “affect heuristic” that allows the decision-maker
to evaluate multiple sources of critical and subtle information and to make
rapid responses without having to necessarily engage in a demanding or
enhanced analytic process (Stanovich & West, 2002). On this basis, a failure
by individuals with ASD to deploy an affect heuristic in complex and uncer-
tain social contexts might limit their intuitive reasoning mechanisms and
thereby their social competence.
Luke et al. (2012) compared the decision making of adults with (Mean
Verbal IQ ¼ 116.4) and without ASDs (Mean Verbal IQ ¼ 114.2) and found
distinct differences in the experiences of the two groups. In the absence of
cognitive differences between the two groups, the differences in decision

making reflect the impact of characteristics linked to the autism phenotype.
In this study, adults with ASDs reported greater reliance on an avoidant
decision-making style and significant difficulties with decisions that had
to be made quickly, decisions that involved a change of routine, and deci-
sions that involved talking to others, in comparison to their nondisabled
counterparts. Decision-making performance was also associated with anxi-
ety and depression, with perceived frequency of interference in decision
making increasing proportionally with levels of anxiety and depression.
The ability to accurately interpret emotions and others’ feelings allows us
to monitor others’ intentions, to predict others’ behaviors or regulate one’s
own behavior. These underlying emotion and perspective taking mecha-
nisms are essential to adaptive decision-making performance but acknowl-
edged to be problematic in individuals with ASD.
Khemka et al. (2013) compared 16 adolescents with ASD with 17 ado-
lescents with other forms of IDD, including mild ID, speech/language dis-
orders, and learning disabilities. Participants in the two groups did not differ
significantly in age (Mean age ¼ 16.2) or IQ (Mean IQ ¼ 70.1). The two
groups did not differ significantly on a measure of their ability to assess
the level of risk inherent in a series of vignette situations involving peer coer-
cion. However, when asked what was the best thing for the protagonist in
the vignettes to do (i.e., decision question), adolescents with ASD were sig-
nificantly more likely than adolescents with other IDDs to give responses
that indicated that the protagonist should comply with the peer coercion.
The adolescents with other IDDs were more likely than their counterparts
with ASD to give responses indicating that the protagonist should resist the
peer coercion. On a measure of decision-making style, the adolescents with
ASD were more likely than the adolescents with other IDDs to report that
when they had a big decision to make, they worried about the decision and
they tried to remember past decisions. A significant negative correlation was
found between worrying about decisions and decision-making responses
that involved resisting the coercion. The fact that the two groups did not
differ significantly on IQ suggests that cognitive limitations cannot account
for the lower levels of resistance and higher levels of compliance exhibited
by the participants with ASD on the decision-making task. These findings
are consistent with the earlier discussion of theories implicating emotional
factors, including high levels of social anxiety, and a pattern of repetitive
and stereotyped behaviors as sources of decision-making difficulty in indi-
viduals with ASD.
The high prevalence of restricted interests in individuals with ASD has

been connected to differences in reward-processing (Damiano, Aloi,
Treadway, Bodfish, & Dichter, 2012) for social and nonsocial stimuli
and consequently differences in motivation to seek and expend effort when
making reward-based choices. The highly salient and consistent behavioral
feature of “rigidity” in individuals with ASD leads them to have atypical
behavioral motivations that underpin aspects of their restrictive and
repetitive interests and behaviors. This is likely to influence their goal
selection during decision making and level of effort (and self-efficacy)
toward optimal goal-directed decision-making behavior. The rigidity
might also interfere with the ability to make effective intuitive/automatic
decisions, lengthening typical reaction time or approaching situations from
a restricted repertoire of responses. The above studies demonstrate how
features associated with ASD can predispose individuals with ASD to
impaired decision making, especially in social situations that require regu-
lation of emotions and motivations.
2.4. Summary of Decision-Making Research with Individuals

with IDD
The research evidence on ways in which decision making may be affected
differently by the underlying conditions of IDD is limited, although emerging.
A look at the overall IDD category by subtypes that are fairly distinct in their
etiology and phenomenological characteristics indicates a wide range of
decision-making performance within the IDD group. However, despite
the heterogeneity in the IDD group and the wide range of decision-making
abilities and skills observed, all of the conditions classified as IDD involve cog-
nitive and/or social limitations. It is apparent that deficits in executive func-
tioning negatively impact the ability of individuals with all types of IDD to
select and coordinate the implementation of effective decision-processing
strategies. Taken as a whole, the research seems to support the development
and application of generally applicable intervention approaches that are based
on insights from current decision-making theories, but with consideration of
the need to differentiate aspects of the interventions to address the particular
difficulties associated with specific subtypes of IDD.
There is an additional need for increased attention to the regulation of
affect and behavior in accordance with long-term goals and consequences
in the case of adolescents, for whom such regulatory demands may already
be an inherent challenge. For instance, adolescents with IDD may be slow in
their maturation, may lack the necessary cognitive capacity, or may be
limited in their emotional awareness, and may need extra regulatory struc-
ture and added supports, and for much longer into their life span, than their
counterparts without disabilities, for whom regulatory supports may become
less necessary with increasing age.
Research based on the study of the etiology of disorders and the resulting
phenotype–genotype associations will surely over time help to elucidate
more clearly the variations in typical and atypical developments of brain,
learning, and behavior, and therefore, decision making. However, with
extant literature still limited in this area, we have focused on the functional
outcomes of genetic and biological factors for decision making by identify-
ing individual differences in the basic processes of cognition, motivation,
and emotion underlying decision making (see Hickson & Khemka, 2013).
Research supports the relevance of each of the three basic processes in
the decision-making difficulties of individuals with IDD. For example, cog-
nitive limitations may include not only reduced processing capacity and
memory but also limitations in the comprehension required for fully under-
standing the nature of a situation requiring a decision (e.g., friendly or
threatening) (Khemka et al., 2013). Motivational differences that may affect
decision making include goal priorities and the relatively weak personal
agency beliefs that have been described as “learned helplessness” in individ-
uals with IDD (e.g., Jenkinson, 1999). There is evidence that emotional pat-
terns, similar to those observed in individuals with IDD (e.g., Wishart,
Cebula, Willis, & Pitcairn, 2007), also play a key role in decision making.
Decision-making effectiveness in individuals with IDD may be limited by
difficulties in accurately identifying the emotions and intentions of others
(emotional context) as well as a lack of the emotional self-regulation needed
to formulate a reasoned response in the face of a threatening situation.
The research with individuals with various forms of IDD indicated that
there were disability-specific ways in which difficulties with these basic pro-
cesses interfered with decision-making effectiveness. A listing of some of the
sources of decision-making difficulty associated with each of these basic pro-
cesses that have been associated with ID, WS, and ASD to date is provided in
Table 6.1.
3. A PATHWAYS MODEL OF DECISION PROCESSING

Over the past 15 years, we have proposed a series of frameworks to
guide decision-making research with people with IDD (Hickson &
Khemka, 1999, 2001, 2013; Khemka & Hickson, 2006). In developing these
Table 6.1 Suggested Sources of Decision-Making Difficulty and Supporting References

by Target Group: Intellectual Disability (ID), Williams Syndrome (WS), and Autism
Spectrum Disorder (ASD)
Target
Source of Difficulty Group Supporting References
Cognition
Intelligence/cognitive capacity ID Hickson et al. (1998, 2012)
Comprehension ID, WS Hickson et al. (1998, 2004, 2012)
Generation of alternatives ID, ASD Hickson et al. (1998), see review by
Hickson and Khemka (1999), Ruble
et al. (2008)
Forecasting of rewards/ ID Willner et al. (2010)
temporal long-term gain
Attention WS Hickson et al. (2004)
Visuospatial processing WS Hickson et al. (2004)
Motivation
Personal agency beliefs ID Jenkinson (1999), Khemka (2000)
Avoidant decision style ASD Luke et al. (2012)
Goal priorities WS, ASD Hickson et al. (2004), Khemka et al.
(2011)
Behavioral flexibility ASD De Martino et al. (2006), Luke et al.
(2012)
Restricted interests ASD Damiano et al. (2012)
Overfriendly and trusting WS Frigerio et al. (2006)
Emotion
Identifying emotions and ID Wishart et al. (2007)
intentions of others/
perspective taking
Emotional cue processing and ASD De Martino et al. (2006)
emotion regulation
Worry and anxiety ASD, WS Dykens (2003), Khemka et al. (2013)
Impulsivity ID Willner et al. (2010)
evolving frameworks, we have drawn upon the body of empirical work with
individuals with IDD as well as the theories discussed in Section 1 of this chap-
ter, especially the descriptive and dual-process theories (e.g., Kahneman,
2011; Selten, 2001; Simon, 1986; Stanovich, 2010, 2011).
Although there is a growing understanding of the sources of difficulty
that can interfere with the decision making of individuals with IDD, knowl-
edge is incomplete about the full constellation of processes that individuals
with IDD employ when faced with the opportunity to make a decision,
especially one involving risk in the real world. Given the wide range of deci-
sion performance differences among individuals with IDD, it is reasonable to
assume that there is no single developmental trajectory by which less nor-
mative to more normative decision-making behavior evolves in individuals
with IDD. Given the strong claims (Albert & Steinberg, 2011; Jacobs &
Klaczynski, 2002) that competence in judgment and decision making does
not necessarily develop along a unidirectional, linear trajectory progressing
developmentally from initial intuition (type 1) to later mature deliberative
thinking (type 2) with age, it is reasonable to explore multiple pathways
or modes of decision processing for individuals with IDD.
In addition, the application of naturalistic decision-making models (see
Greitzer, Podmore, Robinson, & Ey, 2010; Klein, 1997) to explain how
individuals make rapid decisions in emergency or time-critical situations
lends credence to the effectiveness of subconscious, automatic information
processing in arriving at in-the-moment good decisions without having to
engage in a deliberative evaluative process. The findings also underline that
rapid decision making is primed by memory structures and experience that
facilitate recognition and matching of novel situations to previously encoun-
tered situations and subsequent recall of cues, actions, and expectations.
Over time, experience and long-term memory builds up to create nonco-
nscious, instinctive knowing patterns in decision responding (see Allen,
2011; Hammond, 2010; Sinclair, 2010).
The most recent version of our framework, the Pathways of Decision
Processing model shown in Fig. 6.1 (see Hickson & Khemka, 2013 for a
detailed description), offers a working model that can be applied with indi-
viduals with and without disabilities across a range of social decision-making
situations, ranging from everyday decisions about activities with peers to
more complex decisions about interpersonal interactions that may involve
abuse, negative peer pressure, or bullying. It is assumed that most adults
without disabilities possess a full repertoire of decision-making strategies that
allow them to shift flexibly among the four pathways as needed when faced
with various types of decisions. The model thus provides a structure for
Pathways of decision processing
Pathway 4 Decision output Pathway 3

Pathway 1 Pathway 2
Reasoned
Pathway 3 Pathway 3 reflective
Regulatory and
Intuitive automatic inhibitory
controls Use of DM strategy
DM strategy
Higher order Recognition and definition of

hypothetical thinking problem (framing)
Identification of alternatives
Pathway 4 Evaluation of consequences
Selection of choice
Biological/neurological/developmental
Emotion Motivation Cognition
Situational and environmental
Social context Beliefs and culture

Gender Past experience
Figure 6.1 Pathways of decision processing. From Hickson and Khemka (2013).
pinpointing and addressing disability-specific decision-making difficulties.

In the model, we illustrate four alternative decision pathways that individuals
can pursue and highlight the various factors that may impinge upon these
pathways and the ultimate decision output. The model encompasses path-
ways reflecting intuitive decision making as well as pathways based on a
deliberative strategy that provides an overall schema of how one might
engage in a decision-making process in a planful, reasoned way. Although
four component steps of a deliberative decision-making strategy are enu-
merated to reflect a generalized process of reasoned reflective decision mak-
ing, the actual steps and the order in which they might be applied by a
decision-maker in real-life situations may vary considerably.
Informed by the recent theoretical advances discussed earlier in this chap-
ter, and building upon earlier versions of our framework, the pathways model
incorporates the basic mental processes of cognition, motivation, and emo-
tion. Each of these processes influences how well individuals regulate them-
selves to make decisions to adaptively satisfy their goals. Integral to the
decision-making process are the contextual demands of decision making,
including situational and environmental factors consisting of the situation-
specific requirements imposed by different types of decisions. Other contex-
tual factors include the challenges associated with generalization to real-life
situations and the complexity of handling the temporal dimensions of decision
making (e.g., iterative vs. noniterative tasks). Finally, we believe that the bio-
logical/neurological/developmental characteristics of the decision-maker are
key factors in determining which decision pathway will be selected and
applied in specific situations.
The Pathways of Decision Processing model depicted in Fig. 6.1 shows four
alternative pathways that a decision-maker can follow when faced with a
decision.
Pathway 1
This is the intuitive automatic decision-processing pathway that relies
almost entirely on type 1 processing. When retrieved from memory, type
1 processes are deployed rapidly and automatically with little or no effort,
based upon a gist-based representation of the situation. This type of deci-
sion process might be called upon if a person is offered a ride home by a
neighbor.
Characteristics associated with ASD (e.g., difficulties with reading the
emotions and intentions of others and a lack of flexibility) may lead to atyp-
ical Pathway 1 processing patterns. Furthermore, individuals with ASD tend
not to employ the affect heuristic or take in the full emotional context of a
decision-making situation, depriving them of potentially valuable self-

protective, affective cues in situations of possible victimization.
Pathway 2
For certain decisions, processing may be centered almost entirely on a
calculated, reasoned reflective pathway requiring type 2 processing based
on more detailed, verbatim representations. Embedded in reasoned
reflective decision processing is the higher-order hypothetical thinking
necessary for the generation and evaluation of alternatives. Deliberative
decision-making may be called for in situations with serious conse-
quences, such as when a person is faced with a decision about what to
do about a long-term, abusive relationship with a partner or caregiver.
Individuals with ID can be expected to encounter difficulty with mul-
tiple components of reasoned reflective decision processing, including gen-
erating alternatives, applying a step-wise strategy, and especially carrying out
the hypothetical thinking needed to project possible short-term and long-
term consequences of each alternative.
Pathway 3
A third pathway also leads to reasoned reflective (type 2) processing, but
only after regulatory mechanisms override an initial intuitively based
(type 1) decision-making process.
Individuals with various forms of IDD may lack effective mechanisms for
interrupting and overriding an automatic type 1 decision process, that may
have been initiated in response to a seemingly benign request by a caregiver
(e.g., to follow the caregiver into the bedroom), in the event that the request
suddenly appears to threaten their safety (e.g., caregiver tells her/him to
remove clothing) and a shift to type 2 processing may be required to figure
out how to get out of the potentially harmful situation. In the face of neg-
ative peer pressure, adolescents with IDD may have difficulty overriding an
intuitive automatic response (e.g., to use drugs) and turning to a reflective,
goal-driven cognitive control system, which may not yet be fully developed,
in order to consider the options for handling the situation.
Pathway 4
Finally, a pathway that includes individual decisional feedback loops can
develop over time as consequential evidence from repeated decision-
making experiences accumulates. The feedback and experience from
reasoned reflective decision processing can provide an informed under-
standing of alternatives and their possible consequences in a specific
domain such that, over time, a new pathway of decision processing
evolves to create a strengthened and adaptive type of intuitive (type 1)
decision processing in the form of a learned automatic heuristic or

primed response. Klein’s (1998, 2009) description of emergency
workers, who function as expert decision-makers on a regular basis as
part of their jobs, suggests that they rely heavily on this fourth pathway
to build up a repertoire of effective decision actions that they can draw
upon and implement rapidly under the extreme time pressure and high-
stakes conditions of emergency situations.
It is likely that individuals with ID will require systematic training to
replace established, but ineffective, decision-making schemas based on past
experience with decision-making skills and strategies that are based on effec-
tive decision-making prototypes aligned with their goal priorities. In addi-
tion, memory difficulties and limited ability to generalize readily from
experiences may create barriers to the emergence of this pathway for indi-
viduals with ID.
To summarize, our Pathways of Decision Processing model builds upon current
descriptive and dual-process theories of decision making and provides a
broad framework to guide future research in examining the decision-
making styles and abilities of individuals with IDD. By delineating the mul-
tilayered processes underlying decision-making performance, the model
offers a supportive structure for designing interventions aimed at supporting
individuals with various forms of IDD in building a repertoire of effective
decision-making strategies.
4. CONCLUSION
It is clear that decision making is a much more complex process than
that which we envisioned when we began our work in this area over 15 years
ago. However, thanks to the high level of interest and activity in decision-
making research and theory in multiple fields, including economics, psychol-
ogy, and neuroscience, we now know much more about the processes that
underlie effective decision making and the ways in which it can get derailed
for individuals with various forms of IDD. There is a range of functioning for
individuals with IDD, with their level of decision participation in everyday life
varying from complete dependency on others for decision making to virtually
independent levels of autonomy and decision making. Our research is aimed
at finding ways to enable people with IDD to have as much choice and control
as possible over their lives. Providing them with a repertoire of effective
decision-making strategies may enhance their interpersonal relationships, sup-
port their personal safety, and make it possible for them to be involved in their
communities in valuable and meaningful ways. Research indicates that people

with IDD may have fewer relevant past experiences associated with successful
decision outcomes to draw upon. Individuals with IDD, many of whom oper-
ate within serious confines of limited cognitive functioning typically have
social histories characterized by restricted opportunities and experiences. This
presents formidable challenges for researchers seeking to develop interven-
tions for training and supporting them to engage in effective and self-
protective decision making at various points in their life span. In many cases,
building a strong support system is dependent on increasing the awareness,
willingness, and capacity of service providers and systems.
Our Pathways of Decision Processing model (Hickson & Khemka, 2013)
provides a useful framework for the study of decision-making processes
in individuals with IDD. The framework highlights four alternative path-
ways to decision making that have been described in the literature. As a
guide for exploring the nature of effective decision making, it can also allow
us to identify deficiencies in the application of each of the decision-
processing pathways as a basis for designing interventions to increase the
likelihood that individuals with IDD will be equipped to discover an adap-
tive option in a particular situation. Ideally, effective decision-makers should
have a repertoire of decision-making tools that enables the flexible deploy-
ment of all four possible pathways calibrated to the demands of a particular
situation. Further, the demands for decision making may vary substantially
by the type of decision. For example, financial/medical treatment decisions
might require involvement of others and usually are made over a relatively
longer period of time in contrast to decisions relating to personal relation-
ships or social interactions, which are typically more immediate and self-
determined. The framework also delineates the key stepwise components
of deliberative decision making. This allows the careful scrutiny of the ele-
ments of the reasoned reflective decision behavior of individuals with var-
ious forms of IDD so that areas of vulnerability can be identified and
interventions tailored to address them.
More research is needed to fully understand the processes by which indi-
viduals with IDD can arrive at effective decision outcomes in a wide range of
situations. These processes may or may not resemble those followed by non-
disabled and expert decision-makers. Although the experts interviewed by
Klein (1998, 2009) tended to rely on rapid, intuitive processes to access a
workable solution, reliance on rapid, intuitive processes may not necessarily
result in effective decision outcomes for people with IDD due to limitations
in their ability to contextualize and process information.
Further investigation of differences in the processing requirements for

intuitive/automatic versus reasoned/reflective decisions is necessary to build
understanding of the essential components that must be included in
decision-making interventions to facilitate efficient application of the vari-
ous decision pathways identified in our framework. Isolation of the under-
lying factors and assessment of their impact on the different components of
the decision-making process in a variety of situations can provide useful
information about how to design decision-making supports and training.
As shown in Table 6.1, there is emerging evidence indicating that indi-
viduals with various forms of IDD may encounter a range of disability-
specific obstacles to effective decision making when confronted with the
complexities of interpersonal interactions and relationships. The review of
the literature suggests that individuals with ID might lack cognitive capacity
and the experience to be able to fully comprehend and generate alternative
options as well as apply a systematic process for evaluating the possible con-
sequences of each option.
On the other hand, the key difference in how people with ASD make
decisions may be linked more to the ways in which they process emotional
context and handle anxiety during decision making. It has been noted that
individuals with ASD tend to rely less on shortcuts or heuristics for
processing emotional context information and more on detailed processing
of events based on verbatim representations. Decision making during social
interactions can be fast paced and may require simultaneous processing of
large amounts of contextual information containing emotional cues, making
it difficult for people with ASD. However, their tendency toward detailed
processing may be adaptive when solving complex problems that require
analytical reasoning to arrive at logical and consistent choices. More research
is needed to understand the potential trade-offs between cognitive and emo-
tional mechanisms underlying decision making for people with ASD. It will
be important to identify strategies to enhance their flexibility so that they
may effectively select among the various pathways of decision processing
(as outlined in the framework shown in Fig. 6.1) to match the requirements
of a particular decision task. The impact of social anxiety on the decision-
making behaviors of individuals with ASD also requires further study.
In the case of individuals with WS, their proclivity to overfriendliness
toward strangers can result in a predisposition to risky decision making in
interpersonal situations especially those involving coercion or threat of vic-
timization. The type and extent of regulatory input required by individuals
with WS to counter their predisposition and elevate the priority of personal
safety goals during decision making needs to be explored. For both individ-
uals with ASD and WS, research is needed to expand their repertoires of
motivations/goals for application in social interaction situations.
Systematic studies of ways in which decision making may be affected dif-
ferently by the underlying conditions of these and other specific forms of IDD
are still relatively sparse. Thus, we currently have only limited understanding
of how specific etiological factors predispose individuals to adaptive or dys-
functional decision styles. However, as shown in Table 6.1, the emerging evi-
dence does suggest that distinct difficulties are associated with underlying
etiologies and behavioral phenotypes. This creates a pressing need to perform
group comparison studies (ID, singular types of ID, ASD) to verify and expli-
cate the nature of disability-specific differences in decision processing in terms
of the roles of key cognitive (e.g., comprehension, processing capacity), moti-
vational (e.g., personal agency beliefs, goal prioritization), and emotional fac-
tors (e.g., anxiety, recognition of emotional context and regulation of
emotions) deemed essential in decision making.
The Pathways model suggests that, moving forward, the next generation of
research studies needs to explore the potential of differentiated intervention
programs to effectively address the decision-making difficulties and the unique
social vulnerabilities of individuals with various forms of IDD, especially dur-
ing adolescence. Intervention efforts designed to provide individuals with
IDD with effective decision-making skills for protecting themselves from vio-
lence and abuse should draw upon current insights from a range of disciplines
(e.g., psychology, genetics/medical, developmental neuroscience).
Differentiated models of decision making for specific groups with ID and
ASD are needed so that the different mechanisms underlying the develop-
ment and course of decision-making behavior in these groups can be
highlighted. Longitudinal studies are needed to track the development of
perspective taking and decision making in these groups, especially during
the adolescent years. Longitudinal studies are also needed to answer the crit-
ical question of whether individuals with ID, WS, or ASD and other specific
forms of IDD can, over a period of time, develop decision-making profiles
that reflect more adaptive social-behavior outcomes. Ultimately, the ability
of people with IDD to acquire and apply effective decision-making strate-
gies in real-life situations will indicate the extent to which decision making is
a learned skill that can be improved with effective instruction. Further
research will be needed to determine the potential of targeted interventions
to enhance the real-life decision-making capacity of individuals with IDD in
ways that result in meaningful improvements to their quality of life.
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CHAPTER SIX

The Psychology of Decision

differentiated interventions to improve the decision making of individuals with different

People with intellectual and developmental disabilities (IDD) are called

1. THEORETICAL PERSPECTIVES ON DECISION MAKING

1.1. Normative and Descriptive Theories

functions or decision rules to help people maximize expected utility of out-

1.1.1 Heuristics and Biases

1.1.2 Stage-Based Models

1.2. Dual-Process Theories

As an alternative to standard, dual-process theories, Reyna and Brainerd

1.3. Role of Noncognitive Processes in Decision Making

of information processing. In the context of decision making, motivation

employing emotional regulatory strategies can reduce the intensity of a sub-

1.4. Developmental Perspectives on Decision Making

Pertinent to this overall understanding of decision making and risk

1.5. Summary of Theoretical Perspectives on Decision Making

The theories reviewed above provide a backdrop for examining the

2. DECISION MAKING AND IDD

2.1. Research on Decision Making with Individuals with ID

In addition, when people with ID were instructed to apply a multistep pro-

disabilities. Study participants with and without ID responded to vignettes

The study compared two training approaches with a control condition:

In an initial intervention study, we developed and evaluated a six-session

2.2. Research on Decision Making with Individuals with

conditions, including WS, Down syndrome, and Fragile X syndrome, we

Additional concerns included inconsistent attention and engagement as well

2.3. Research on Decision Making with Individuals with ASD

cognitive differences between the two groups, the differences in decision

The high prevalence of restricted interests in individuals with ASD has

2.4. Summary of Decision-Making Research with Individuals

3. A PATHWAYS MODEL OF DECISION PROCESSING

Table 6.1 Suggested Sources of Decision-Making Difficulty and Supporting References

Pathway 4 Decision output Pathway 3

Higher order Recognition and definition of

Emotion Motivation Cognition

Situational and environmental

Social context Beliefs and culture

pinpointing and addressing disability-specific decision-making difficulties.

decision-making situation, depriving them of potentially valuable self-

decision processing in the form of a learned automatic heuristic or

communities in valuable and meaningful ways. Research indicates that people

Further investigation of differences in the processing requirements for

Smith, D. C. (1986). Interpersonal problem-solving skills of retarded and nonretarded chil-

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