Intellectual Disability a board certified subspecialty?

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toothless rufus

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Is I.D. a board certified subspecialty in psychiatry? Trying to set up an elective, but my school requires this info. Is this the same thing as Development Disabilty aka Neurodevelopmental disabilty? The last one I did find listed on the american board of medical specialties as a recognized subspecialty of psychiatry.
http://www.abms.org/who_we_help/physicians/specialties.aspx

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I think there are forces at work trying to make it one.

It is the supposed politically correct term for Mental ******ation. I am not sure the new label is much better though. Not sure that the old label is that bad other than the stigma associated with it.
 
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Disability is usually the province of forensic psychiatry.

The following is troubling to me. A common problem I've seen in disability evaluations is they are done by the treating physician. This creates several conflicts of interest. In evaluations where the law is involved, malingering has been found to be present in a significant portion--on the order of 30%, sometimes actually much higher depending on the study.

The treating physician is in a position where 1) they often cannot really tell if the person is telling the truth or not (e.g. "Doctor I have panic attacks!" As we well know, in the outpatient setting, it is rare for a doctor to actually witness the attack. It's one thing to treat something where a person is reporting to you that they want the help for the alleged problem, but to write a report saying that this person in fact has it to a court of law?) 2) The doctor is supposed to advocate for the patient. How can a doctor objectively consider malingering when this doctor is supposed to have a fiduciary responsibility to the patient? 3) Most doctors do not understand the legal dynamics of what is going on. Several doctors I've seen will honor any patient's request for a disability evaluation without performing a real evaluation.

As for "intellectual disability", that is anyone's fair game. Some argue this is handled in general psychiatry, some argue child psychiatrists are best at handling it.
 
Is I.D. a board certified subspecialty in psychiatry? Trying to set up an elective, but my school requires this info. Is this the same thing as Development Disabilty aka Neurodevelopmental disabilty? The last one I did find listed on the american board of medical specialties as a recognized subspecialty of psychiatry.
http://www.abms.org/who_we_help/physicians/specialties.aspx

No.
I do know of triple-boarded physicians who 'specialize' in this sort of thing.

-AT.
 
Disability is usually the province of forensic psychiatry.

The following is troubling to me. A common problem I've seen in disability evaluations is they are done by the treating physician. This creates several conflicts of interest. In evaluations where the law is involved, malingering has been found to be present in a significant portion--on the order of 30%, sometimes actually much higher depending on the study.

The treating physician is in a position where 1) they often cannot really tell if the person is telling the truth or not (e.g. "Doctor I have panic attacks!" As we well know, in the outpatient setting, it is rare for a doctor to actually witness the attack. It's one thing to treat something where a person is reporting to you that they want the help for the alleged problem, but to write a report saying that this person in fact has it to a court of law?) 2) The doctor is supposed to advocate for the patient. How can a doctor objectively consider malingering when this doctor is supposed to have a fiduciary responsibility to the patient? 3) Most doctors do not understand the legal dynamics of what is going on. Several doctors I've seen will honor any patient's request for a disability evaluation without performing a real evaluation.

As for "intellectual disability", that is anyone's fair game. Some argue this is handled in general psychiatry, some argue child psychiatrists are best at handling it.

Are you saying that people malinger and pretend to have MR? I think that would be extremely hard to pull off. MR affects everything from grooming to body habitus to dentition to past work history to the classes a person was in in third grade. If it's the result of chromosomal abnormality or metabolic disease, then other symptoms should be apparent too--and there are tests for those diseases. MR is all pervasive. I suppose a person could malinger and pretend to have very mild MR to get out of military duty or something, but wow, it would be hard. Can't IQ testing or school records from before a person was old enough to think of malingering sort that out? Props to anyone so good an actor they could do that!

If someone fraudulently uses funds obtained through malingering MR--that sort of proves they aren't MR, so what's the point?
 
I think there are forces at work trying to make it one.

It is the supposed politically correct term for Mental ******ation. I am not sure the new label is much better though. Not sure that the old label is that bad other than the stigma associated with it.

Why? There is no treatment. What would this new subspecialty do, medically speaking?
 
Are you saying that people malinger and pretend to have MR? I think that would be extremely hard to pull off. MR affects everything from grooming to body habitus to dentition to past work history to the classes a person was in in third grade. If it's the result of chromosomal abnormality or metabolic disease, then other symptoms should be apparent too--and there are tests for those diseases. MR is all pervasive. I suppose a person could malinger and pretend to have very mild MR to get out of military duty or something, but wow, it would be hard. Can't IQ testing or school records from before a person was old enough to think of malingering sort that out? Props to anyone so good an actor they could do that!

If someone fraudulently uses funds obtained through malingering MR--that sort of proves they aren't MR, so what's the point?

There are parents who coach their kids to act like they are ******ed so they can get SSI for them - and some people have actually managed to pull it off. :thumbdown:
 
Ohhhh yes they do!! Not at all uncommon in a forensic setting.

How on earth can they pull that off? Couldn't old school records prove otherwise? Or, like rph is saying, are these cases where parents are coaching their children? But children aren't good liars, are they?

In any case, kids applying for MR disability should all have pediatricians working them up for the cause of the MR, no? Most cases are idiopathic but at least that would scare off some malingering parents... And the fake cases could be identified more easily. Geez, even schoolyard kids can tell who's really "slow" and who is not. Perhaps they should testify too! I'm sorry, this is ridiculous! (I'm not trying to be mean, I just don't understand. Faking panic attacks--that I can buy.)

I get the impression that disability assessment is not all that rigorous. I mean, if you can fool a judge that you or your kid is MR--that is weird.

Poor kids.
 
Are you saying that people malinger and pretend to have MR

Yes.

Don't look at this like it's a black and white thing. Remember, several psychiatric issues exist on a spectrum.

There are several people with borderline intellect, MR, or even with normal or even higher IQs who are willing to do anything for a monthly check from the government.

It's not out of the ordinary for someone who has MR to be planted with the idea that if they can be placed on disability they could get "free money." Such a person could be perfectly capable of working. Remember, disability doesn't mean the person can't be a doctor. It bottom line means the person cannot find work that is within reason to find. Several people with MR are capable of working in several jobs such as a bagger in grocery store, an assistant in an office, even positions that people without MR would normally carry with the right training.

Some people I've noticed actually coach people into saying the key words so they could get disability.

A big problem with disability is once a person is on it, a significant portion don't go back to work.

I've seen several people believing that just because they have a disorder, they deserve disability--> including MR people that are capable of working. When I reject their disability, it creates a strong rift between the patient and I. It harms the therapeutic relationship. Several treating doctors, for that reason, are willing to allow all of their patients a report recommending disability, whether the person does or does not have the legal criteria justifying it. IMHO forensic evaluations for disability should not be done by a treating physician. It should be done by a neutral doctor with no treating relationship with the evaluee.
 
IMHO forensic evaluations for disability should not be done by a treating physician. It should be done by a neutral doctor with no treating relationship with the evaluee.

The law doesn't already require that? The conflict of interest you're describing is inevitable and obvious. I can't believe that disability law doesn't already address this. Ugh. Having now worked at the VA for awhile, and at a county hospital where almost 0% of the psych patients have jobs, even those that could, I am astonished at the mental health disability situation in the US.

I can understand that people with mild MR who really could work in some capacity would be motivated to portray themselves as completely unable to work--but again, are there no objective criteria to sort this out?

Same with bipolar, same with any mental health problem. I see your point that MR is similar to other illnesses in that it exists on a spectrum of what people can do. Nonetheless, I'm confused as to why our courts don't demand objective criteria for patients to prove that they're at the point on the spectrum where they can't work at all. It's sad, because there are so many Americans who desperately want jobs right now, and people malingering to get out of them, meanwhile.

Who cares what the patient's own doctor says? That testimony is obviously biased. It should just be thrown out. I'm so jaded about disability I'm starting to wonder if any doctors can sort it out, period. It's just like repeat detox admissions at the VA--I'm starting to think doctors would rather see a patient die from things like cirrhosis over time or wither away on disability than confront the patient with what's really wrong--namely, in this case, malingering.
 
The law doesn't already require that?

Unless there's a state that does based on their written laws, as far as I know, no.

From my own experience, the overwhelming majority of disability evaluations are done by the treating doctor, and unfortunately, the overwhelming majority of these reports, I do not trust.

These doctors do not have forensic training and may not even understand the legal definitions of disability. They may, for example, in a desire to help their patient, or in a less-than-honest/lazy move (so they won't have to deal with an angry patient), just write a report favoring disability.

The few times I've seen a "real" forensic evaluation is when an insurance company is put in a situation where they have to pay big bucks to someone allegedly harmed during work. The insurance company, not wanting to pay the big bucks, hires a forensic doctor to give a "real" evaluation.

For these reasons, I have found disability evaluations extremely frustrating when it's my own patient asking me to write an evaluation. I've started a policy that anytime I write a report on disability, especially if it's an outpatient, that I pretty much state that I can only go on the patient's own reported symptoms. Unless it's schizophrenia, schizoaffective disorder, dementia, or a disorder where the objective symptoms I can clearly see in the office to the point where I can tell it will affect their ability to work in a job that does not require much cognition, (e.g. a bagger in a grocery store), I'll pretty much write that I can only see the person's symptoms based on what they're telling me, and in evaluations like this, the risk of malingering, while not the majority, is still significant.

Even in inpatient, in a short term care facility. I'm not so willing to write a report for disability. In most of those cases, the patient improves dramatically in a few days. It's hard to tell if they can work or not. In these cases, I'd definitely recommend an occupational therapy assessment before the patient is discharged for added insight.

From there on it's really up to the judge. Insurance companies and government care will not reimburse doctors most of the time to write disability evaluations, so unless the Court orders me to do a "real" evaluation, (for which they're going to have to pay for it), or they order it upon a neutral doctor (which is what I recommend in the letter), there pretty much will be no evaluation by such a doctor.

And unfortunately, most judges I've seen don't understand this. They think we doctors are more capable than we are. Just like IM doctors often consult us for reasons that are ridiculous (e.g. "We need to know if he's telling the truth or not.") judges I've seen don't understand either. I've had several conversations with judges asking them to change their order upon me which is clearly inappropriate, but the worse of 2 evils. (E.g. a judge ordered I write an insanity evaluation when the defendant didn't want to use an insanity defense. The judge wanted to push this defense on the patient which is in violation of the Sixth Amendment. The judge, being the legal expert, not me should've known that, but for some reason this judge couldn't tell. I'll remind the judge that there's such a thing called the Sixth Amendment defining that a defendant has the right to choose their defense, and it cannot be forced upon them by the judge. I've had this happen several times. )
 
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How on earth can they pull that off? Couldn't old school records prove otherwise? Or, like rph is saying, are these cases where parents are coaching their children? But children aren't good liars, are they?

In any case, kids applying for MR disability should all have pediatricians working them up for the cause of the MR, no? Most cases are idiopathic but at least that would scare off some malingering parents... And the fake cases could be identified more easily. Geez, even schoolyard kids can tell who's really "slow" and who is not. Perhaps they should testify too! I'm sorry, this is ridiculous! (I'm not trying to be mean, I just don't understand. Faking panic attacks--that I can buy.)

I get the impression that disability assessment is not all that rigorous. I mean, if you can fool a judge that you or your kid is MR--that is weird.

Poor kids.


I should have clarified, I meant in a criminal setting. I'm sure it happens in disability claims as well, but I'm not as familiar with that. It's not uncommon for people to malinger MR when they are trying to appear incompetent to stand trial or trying to get mitigating factors in a death penalty case, or to avoid execution.
 
Intellectual disability is more the domain of ortho.

:D

I keed, I keed!!!!
 
Why? There is no treatment. What would this new subspecialty do, medically speaking?

What?!!!

First of all this is not all about malingering vs not malingering.

Just because there is no cure doesn't mean there is no treatment.
I am not a specialist but I know that you can aid with practical skills such as ADLs as well as social skills. You can help with overcoming cognitive shortcomings. Something just as simple as helping the person get placed in the right place such as a sheltered workshop etc.

Just because a person is mentally deficient doesn't mean they are hopeless.
 
What?!!!

First of all this is not all about malingering vs not malingering.

Just because there is no cure doesn't mean there is no treatment.
I am not a specialist but I know that you can aid with practical skills such as ADLs as well as social skills. You can help with overcoming cognitive shortcomings. Something just as simple as helping the person get placed in the right place such as a sheltered workshop etc.

Just because a person is mentally deficient doesn't mean they are hopeless.

No, I don't think people are hopeless just because they are mentally impaired (I wouldn't say deficient!). I don't think that at all. I just wondered if this specialty should fall within the realm of psychiatry. It doesn't seem like we can offer psychotherapies or medications that would actually have an effect and improve the person's cognitive abilities. When I said "there's no treatment"--I meant that in a narrow medical sense. Isn't it true that there's no proven way to raise IQ using known medical interventions?

Obviously there are social interventions that can help cognitively impaired individuals to become more socially functional. But placement in sheltered workshops, etc--does this type of intervention require an MD? I would think that bolstering the existing services for the special needs population might help them more.

Of course I could be wrong and there is lots of work for MDs to do in this area. I'm just going on what I learned in medical school and my limited experience working with this population in residency--I've found that by and large, the focus is on liaisoning with social workers. What could MDs offer that social workers and related professionals couldn't?
 
Why? There is no treatment. What would this new subspecialty do, medically speaking?

While I don't think there needs to be a new subspecialty exam/certification, there is a definite need for psychiatric tx for many of the mentally ******ed. Mood and psychotic disorders are common, but present differently than in the non-******ed. Often meds are needed for aggressive behavior. Many of the MR have seizures, and the psychiatrist treating them needs to be aware of drug interactions with anti-epileptics.
 
While I don't think there needs to be a new subspecialty exam/certification, there is a definite need for psychiatric tx for many of the mentally ******ed. Mood and psychotic disorders are common, but present differently than in the non-******ed. Often meds are needed for aggressive behavior. Many of the MR have seizures, and the psychiatrist treating them needs to be aware of drug interactions with anti-epileptics.

Another area is with benzos. They can have a serious paradoxical reaction and become violent. I have seen multiple (5-10) instances of a psychotic reaction, mild to 1 time severe, with keppra.

As far as subspeciality, while it isn't for me, I can see a need. I don't think I would do it but just looking at percentages, the intellectually disabled represent 2.5% of the population and then there are the developmentally disabled.
 
Another area is with benzos. They can have a serious paradoxical reaction and become violent. I have seen multiple (5-10) instances of a psychotic reaction, mild to 1 time severe, with keppra.

Don't forget that benzos depress the CNS. While the paradoxical reaction is something to consider, and it's a reason to steer away from benzos in those that have a low intellect, in those that don't have the paradoxical reaction, the long term use of a benzo will possibly reduce their CNS function.

I'm not exactly in my happy place now with meds. I've just taken over a forensic unit last week and 3/4 of the patients I've inherited are all on meds where I'm thinking "WTF!!!"

E.g. MR person in 6 mg of Ativan a day.
Depressed person with an anxiety disorder on benzos only.
Sexual offender stalked whose court day to determine if he'll stay in the hospital or be discharged is up in only a few days and the previous psychiatrist did little to assess this guy's future risk of stalking his victim again, and that psychiatrist had this guy for several months. The guy was put on lithium months ago, and the psychiatrist never put in an order to check his lithium level!

I'm kinda ticked right now.
 
Another area is with benzos. They can have a serious paradoxical reaction and become violent. I have seen multiple (5-10) instances of a psychotic reaction, mild to 1 time severe, with keppra.

As far as subspeciality, while it isn't for me, I can see a need. I don't think I would do it but just looking at percentages, the intellectually disabled represent 2.5% of the population and then there are the developmentally disabled.

Well, 1/3 of the US population is overweight if not obese. Should obesity become a subspecialty of IM then? Would that help reduce obesity rates?

And similarly, borderline personality is often mismanaged or misdiagnosed. But we don't have a subspecialty for that, or for Axis II conditions in general.

Just because a problem isn't adequately dealt with by general psychiatry--does that mean it needs to become a subspecialty? That is my question--I'm not trying to debate, since there may be more to this than I know, but I'm just curious. Instead, shouldn't general psychiatry be asked to do a bit more, at least until it becomes overwhelmed and the information becomes too complex for a generalist? Personally, I don't feel that general psychiatry is as all-encompassing or complicated as general surgery, general pediatrics, or general IM, so to branch off into a subspecialty just for one type of illness category that is going to rely on medications and principles already in use by general psychiatry, and also heavily depend on social work interventions--now I am getting confused as to how psychiatry determines what counts as a "subspecialty."

Does anyone actually know how subspecialties in psychiatry are formed? Is there a guiding rationale behind it?
 
Well, 1/3 of the US population is overweight if not obese. Should obesity become a subspecialty of IM then? Would that help reduce obesity rates?

And similarly, borderline personality is often mismanaged or misdiagnosed. But we don't have a subspecialty for that, or for Axis II conditions in general.

Just because a problem isn't adequately dealt with by general psychiatry--does that mean it needs to become a subspecialty? That is my question--I'm not trying to debate, since there may be more to this than I know, but I'm just curious. Instead, shouldn't general psychiatry be asked to do a bit more, at least until it becomes overwhelmed and the information becomes too complex for a generalist? Personally, I don't feel that general psychiatry is as all-encompassing or complicated as general surgery, general pediatrics, or general IM, so to branch off into a subspecialty just for one type of illness category that is going to rely on medications and principles already in use by general psychiatry, and also heavily depend on social work interventions--now I am getting confused as to how psychiatry determines what counts as a "subspecialty."

Does anyone actually know how subspecialties in psychiatry are formed? Is there a guiding rationale behind it?

Lumpers vs Splitters.
 
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