Spectators of the Rio Paralympic Games will assume that all competitors have had their disability assessed to appropriate medical criteria, and that the competition between them is fair. Unfortunately, in the intellectual disability (ID) class, that assumption may not be correct.

INAS is the international federation for athletes with ID, and it created the criteria for competing in the ID class. The Sports Integrity Initiative has learned, however, that the criteria used by INAS are inconsistent with those used by the rest of the world for diagnosing ID, meaning that some of the athletes we see winning in Rio in the ID class may not, according to international standards, be classified as ID. To put this another way, the criteria in respect of intellectual functioning used by INAS are more lenient than internationally recognised ID standards. This means that athletes who are deemed to have ID under internationally recognised standards are having to compete against athletes who may not be eligible under those criteria, creating a potential competitive advantage for ‘higher functioning’ athletes.

International standards

INAS claims that its intellectual functioning criteria are based on the criteria prescribed by the World Health Organisation (WHO) and the American Association on Intellectual and Developmental Disability (AAIDD). Those criteria have become reference points for the global medical community.

The criteria are based on an IQ test score (approximately 69 or less for the WHO or 70 or less for the AAIDD (see page 27 of the 2010 AAIDD Definition Manual)) and, crucially, a clinical assessment.

The INAS intellectual functioning criteria

An athlete will satisfy the INAS intellectual functioning criteria for the ID class simply if they score 75 or lower in an IQ test. No clinical judgment is required to assess whether or not the score achieved reflects the athlete’s actual intellectual functioning and so there is no way of knowing if the IQ test score has been manipulated or is otherwise not reflective of the athlete’s actual intellectual functioning.

There are, thus, two fundamental problems with the INAS criteria:

1. The first is that the current INAS intellectual functioning criteria use a strict cut off score, and there is no exercise of clinical judgment to interpret it (as there is under the WHO and AAIDD criteria). That means that qualitative factors, such as environmental issues, fatigue, and comorbid diagnoses such as Autism – as well as certain types of medication – which may cause an IQ score to be artificially and misleadingly low, are not taken into account under the INAS intellectual functioning criteria (so an athlete with good intellectual functioning could slip through the net). In contrast, under the WHO/AAIDD criteria, potential IQ score influencers would be picked up and factored into the assessment by the diagnosing clinician. The exercise of clinical judgment is important because IQ tests are imperfect, and there is an associated margin of error which needs to be taken into account – as acknowledged by the WHO and AAIDD criteria.

2. The second problem, and perhaps the more obvious one, is that the INAS IQ cut-off score is 75, whereas cut-offs of approximately 69 and 70 are referenced by the WHO and AAIDD. This discrepancy appears to originate from a basic mathematical error on INAS’ part. INAS has previously claimed that it uses a cut-off score of 75 because that is ‘2 standard deviations below the mean’ of 100 – but that is simply wrong. Two standard deviations below the population mean is 70, not 75.

To illustrate these problems, assume an athlete has an IQ score of 75. That athlete is going to satisfy the INAS intellectual functioning criteria, but would not satisfy the international standards set by the WHO/AAIDD (unless in special circumstances clinical judgment determined otherwise). Even athletes with an IQ score of less than 69 do not necessarily satisfy the WHO/AAIDD intellectual functioning criteria as that depends on the additional assessment of a diagnosing clinician to interpret the IQ score.

The practical effect of the INAS intellectual functioning criteria

The practical effect of the current INAS intellectual functioning criteria is that within the ID class, athletes who are deemed to have ID by the appropriate criteria are having to compete against athletes who may not be eligible under those criteria.

Perhaps in cases of diagnosing individuals for ID for the purposes of delivering a social service, an argument could be made for less restrictive criteria in order to serve a broader range of cognitive and emotional disabilities without necessarily disadvantaging the correctly defined ID population. However, in case of sport competition the situation is reversed, because less restrictive criteria allow higher functioning athletes to compete against truly ID athletes, thus exposing the truly ID athletes to significant competitive disadvantage.

The INAS intellectual functioning criteria not only depart from international standards, but they are also in breach of both the IPC Classification Code, and the IPC Code of Ethics. The IPC Classification Code requires INAS to implement criteria based on internationally-recognised ethical and research practices, and which ensure fair and equitable competition. Similarly, under the IPC Code of Ethics, INAS is obliged to safeguard both ‘the dignity of the individual and of the sport’ and ‘athletes’ interests, priorities and opportunity to participate in fair competition and excel in sport’. INAS is also obliged under the IPC Code of Ethics to avoid any behaviour or action that would tarnish the reputation of the Paralympic Movement.

By allowing athletes who are categorised as having ID by INAS’ own ‘made up’ standards (and not WHO/AAIDD standards), to compete against athletes who have ID according to generally accepted international standards, INAS is failing to honour its obligations. In fact, the INAS Criteria – as they currently stand – have the potential to undermine the very purpose of the Paralympic Movement in respect of ID sport.

The refusal of INAS and the IPC to correct the criteria

The Sports Integrity Initiative has learned that INAS has been repeatedly informed of the errors associated with its criteria. Syd Lea – an ID athlete – and his parents have pleaded with INAS to correct its criteria for six years, without success. The Sports Integrity Initiative has also seen a formal complaint about INAS’ criteria that was sent to the IPC on behalf of Mr. Lea on 22 July 2016, and on which the IPC has declined to act. Instead, the IPC simply referred the matter back to INAS.

INAS acknowledged the complaint. ‘Since the criteria was revised and agreed in the early 2000s we have received just one formal complaint which was investigated and answered by INAS (on multiple occasions) and by the International Paralympic Committee’, read a statement emailed to The Sports Integrity Initiative by INAS.

INAS’ response

INAS said that it ‘strongly refuted’ the idea that athletes classed as ID under internationally recognised standards were having to compete against athletes that would not meet those criteria, due to the INAS classification system. However, it did not deny that it was using its own criteria for ID classification rather than the international standards of the WHO and the AAIDD, or otherwise attempt to explain how they are consistent.

‘IQ is just one component of a comprehensive assessment for intellectual disability (with all leading authorities increasingly placing equal or greater emphasis on the assessment of Adaptive Behaviour)’, read its emailed statement. ‘IQ is rarely now quoted with a specific cut-off but instead with words such as “approximate”, “in the range of” or similar…emphasising the need for careful clinical judgement rather than a hard cut-off’.

INAS’s recognition of the need for clinical judgment appears odd, since a specific requirement for clinical judgment is absent from its intellectual functioning criteria. INAS does insist that a form of clinical judgment is used when it assesses ID. ‘When considering an athletes eligibility, INAS takes into account the full assessment and not just the IQ score’, it said. However, the issue is that the INAS intellectual functioning criteria do not contain a requirement to consider anything other than IQ score. That is obviously inconsistent with what the AAIDD says in respect of its own cut off of ‘approximately’ 70 (see page 35 of the 2010 AAIDD Definition Manual).

‘The intent of this definition is not to specify a hard and fast cutoff point/score for meeting the significant limitations in intellectual functioning criterion of ID. Rather, one needs to use clinical judgment in interpreting the obtained score in reference to the test’s standard error of measurement, the assessment instrument’s strengths and limitations, and other factors such as practice effects, fatigue effects, and age of norms used (see following section). In addition, significant limitations in intellectual functioning is only one of the three criteria used to establish a diagnosis of ID.’

‘The use of “approximately” reflects the role of clinical judgment in weighing the factors that contribute to the validity and precision of a decision. The term also addresses statistical error and uncertainty inherent in any assessment of human behaviour. In that regard, the decision-making process cannot be viewed as only a statistical calculation.’

INAS says that its ID criteria setting an IQ limit at 75 was ‘agreed in full consultation with AAIDD and WHO, and with the full backing of the International Paralympic Committee’ about 14 or 15 years ago. ‘Discrepancies between different IQ tests, error margins in scores and the Flynn effect all mean that quoting a specific threshold or diagnosing intellectual disability on the strength of a single measure is medically weak’, it states. Be that as it may, INAS has not explained why a higher IQ score threshold was set in its criteria than those specified in the WHO/AAIDD criteria. If an IQ score is not important, then why not agree the same score as that specified by internationally recognised criteria? Also, in the absence of a defined requirement to use clinical judgement, the INAS classification system in respect of intellectual functioning appears to ignore clinical judgment and provide an IQ limit of 75 as a strict cut-off point.

INAS explains that:

‘All athlete assessments are undertaken by qualified psychologists trained in the assessment and diagnosis of intellectual disability. They are required to produce a report that includes an assessment of intellectual functioning (IQ), Adaptive Behaviour and supplemented by an overview of the athletes history, development and current circumstances – taking information from a wide range of sources. This results in a comprehensive assessment report which is checked at a national level by a nominated National Eligibility Officer (also a qualified psychologist) and then considered by at least two different members of a panel of international psychologists.’

‘Athletes entering Paralympic competition have also, since around 2009/10, been required to undertake sports classification (as all other impairments groups do)’, continues INAS’ statement. ‘This measures the impact of intellectual disability on sports performance and ensures the athlete demonstrates a minimum level of impairment in the sport. Taken together, this is one of the most comprehensive assessments undertaken in disability sport.’

As INAS’ response illustrates, it would appear that it considers its ID classification system to be fair and proportionate. However, the fact remains that its classification system is different to the one used by the WHO and AAIDD. It appears that INAS does carry out its own interpretation of clinical judgement when assessing ID athletes – but not specifically in relation to the intellectual functioning element of its criteria, where a strict IQ cut off of 75 is used.

Conclusion

The reputation of the Paralympic Games suffered a huge blow in 2000 when it emerged that members of the Gold-medal winning Spanish basketball team in the ID class did not in fact have ID and had not even been tested. The class was consequently suspended from competing in the Paralympics, and was not re-admitted until London 2012.

Now the Paralympic Games are under further scrutiny, as one of Britain’s top Paralympians, Bethany Woodward, has quit team GB alleging more able-bodied athletes are being wrongly classified to boost medal prospects. Woodward, who has cerebral palsy told The Sunday Times: “they’ve brought in people who are not like me in terms of disability, what’s the point?”.

The Sunday Times also reported a number of other athletes and experts asserting that the classification system was unfairly penalising more seriously disabled athletes. For example, Italian athlete Oxana Corso, supporting Woodward, said that she felt “duped by a mocking system more focused on putting on a show than supporting disabled athletes”. Michael Breen, the father of British Paralympian Olivia Breen, and also a lawyer, claimed there has been “false and reckless” classification intended to increase British success, and that “UK Athletics are getting athletes classified without appropriate supporting medical evidence to increase their gold medal count”.

The Guardian also reported that an internal email sent in 2014 by Mike Cavendish, performance programme manager at British Athletics, recorded the following concerns: ‘On some occasions athletes (and national Paralympic committees/national governing bodies) are thought to have knowingly pursued classifications that they know to be incorrect, simply to gain a competitive advantage’. Cavendish reportedly went on: ‘Unfortunately despite IPC Athletics’ recent introduction of the Medical Diagnostics Form (MDF) prior to classification, the process isn’t always robust enough to spot these individuals’. UK Athletics will reportedly launch an inquiry, after the 2016 Paralympics, into the classification of Paralympic track and field athletes in relation to such concerns.

Steve Long is the father of Paralympic Champion Jessica Long, who has held multiple World Records, and has won 12 Gold medals across three summer Paralympics. He notes:‘The swimmers have discovered that they can intentionally conduct themselves in a way that misrepresents the severity of their disability. By doing this, they are able to scam the classifiers and compete in the wrong disability class.’ He goes on: ‘If the IPC doesn’t step in to ensure fair play, the “dopers” of the Paralympics will run away with the records and medals!’

With so much controversy and scrutiny, and with the athletes themselves losing faith in the classification systems, the IPC must now act swiftly and decisively to restore confidence in the integrity of its competitions and regain the trust of athletes and the public. Certainly in respect of the ID class specifically, if the IPC does not act quickly and forcefully, it is questionable whether the class – the criteria for which appear open to manipulation – can survive under its current guise.