When assessing a patient on the psychiatry oral board exam – and this holds true for the adult and the child adolescent exam – who appears to have mental retardation or developmental delay, you must expect to be asked questions relevent to this topic. And yet, in my experience, many candidates are not prepared to do so. In fact, this topic makes them uncomfortable to the point that they lose their emotional equilibrium and start performing more poorly on the rest of their exam. Here are some simple tips to help you handle these cases better.
1. Estimate a Person’s Intelligence By Estimating Their Grade In School
Even if you do not work with developmentally delayed children, adolescents or adults, you can still do a reasonable job of estimating a person’s intelligence and related level of independence, by comparing them to normally developing kids you know. Here is how it works. When you are interviewing such a person, ask yourself, “If this were a kid I knew, what grade do they seem like they’d be in. (Please note I do not mean to be demeaning to people with developmental delays. Heaven knows their lives are often quite challenging. My approach is simply to give you a quick and fairly accurate way of knowing how to best treat them. I believe you will be left with more confidence on knowing what precautions to take, what level of supervision you will recommend, etc. That’s my goal here.)
An adult with mild mental retardation is functioning at approximately a sixth grade level. This is a middle schooler. Ask yourself: Could this sixth grader live entirely independently? Probably not. Could they live in their own apartment with supervision? Probably. After all kids on the prairie in the 19th century were probably much more adult-like and independent than our overly-supervised kids are today. Could a sixth grader hold a job? Yes, if it had adequate supervision, and the job did not demand too much initiative or complex problem-solving.
An adult with moderate mental retardation is functioning at approximately a second grade level. This is an elementary school child. Could a second grader go out shopping alone? I could imagine them going to the grocery store around the corner. It would probably help if they had a written list of groceries. I would probably show them how to do it first and then supervise them at the beginning to assure myself they were doing ok. What I’m about to say now, seems reasonable for someone on the upper range of moderate. I could imagine such a person getting on a bus and traveling to a well-established stop and then either being met there or having to walk a short distance to a school or workshop. Could I imagine a second grader living independently? No, of course not. Being left unsupervised for a weekend? Also, no. For an afternoon. Yes. Overnight? Probably not. Could I imagine them keeping a budget for the month? No.
What else do you teach second graders? You teach them what to do in an emergency. They should know how to call 911, to know their address and phone number, and how to reach their emergency contacts. They should know that there are bad people in the world who could hurt them and that shouldn’t talk to strangers.
An adult with severe mental retardation is a person who needs round the clock supervision. They know only a few words that they can verbalize or sign: drink, food, bathroom. This is a person who may need the same level of care, on the low end, as an infant needs, to on the higher end, a toddler needs. They may or may not be toilet trained. They need direct assistance in self care, dressing, eating, and hygiene.
If you are assessing a person younger than an adult who has developmental delay, adjust the grade level downward. For instance a 14 year old with mild MR may be at the 3rd or 4th grade level. And a 14 year old with moderate MR is at a preschool or kindergarten level.
Recall that IQ is the mental age divided by the chronological age. So an IQ of 50 (that’s the border between mild and moderate MR) reflects a 20 year old person functioning at a 10 year old level. What grade is a 10 year old in? Fourth grade. Note that once a person reaches adulthood you don’t keep adding to the chronological age. So, for example, if a person aged 50 years has an IQ of 50, that does not mean that they are functioning as a 25 year old! (I wish that were the case!) So an adult, of whatever age, is considered to have a chronological age of about 20 years.
2. Make Your Questions Developmentally Appropriate
True story: One doctor interviewing a young adult with unmistakable Down Syndrome features, opened the interview with this request. “Please qualitatively describe your psychiatric symptoms.” (I’m not sure how well I myself could handle such a question.)
Now, when interview a person who does NOT have dysmorphic features, (that is, features like those of Down Syndrome, Fragile X, FAS), then at the start of the interview you are unlikely to suspect developmental delay. Ways to start suspecting it as you progress through the interview are when you note any of the following features.
* Comprehension is limited. As a reaction, you find youself starting to ask questions with simpler syntax and with more common vocabulary (that would not include the word ‘qualitative!”
* Expression is limited. Responses are unelaborated, vocabulary use seems below grade level or age, and syntax is simple.
* Knowledge of current events is limited.
* Ability to ‘connect the dots,’ weigh options, make decisions that reflect goals and values are all aspects of reasoning ability, and are features that can be seen during a clinical interview. Reasoning ability is perhaps the hallmark features of intelligence, after all.
3. Focus On Function
In the interview you should screen for (using simple language) the core psychiatric syndromes as you would in any other psychiatric interview. Assess for depression, mania, psychosis, anxiety, substance use. This part of the assessment is done relatively well in the candidate interviews of persons with MR that I have observed. However, there need be three additional areas of focus when interviewing a person with MR. (The following questions are based on an interview with a teen with MR.)
A. Assessment of Function: this is done by querying the instrumental activities of daily living that are appropriate for the patient’s age and estimated intellectual level. Examples include the following questions: Do you dress yourself all by yourself or does mom help you? Do you brush your teeth by yourself? How about taking a shower or bath – do you do it yourself or with mom’s help. What kind of chores do you do around the house? Do you make your own meals? For instance, can you make cereal for yourself for breakfast? How about a sandwich? Are you allowed to leave the house by yourself? Are you allowed to go to school by yourself?
B. Assess Risk: We routinely assess suicide and homicide risk with all patients. With the MR patient, make the following adjustments. Ask about self-injurious behaviors as for example: “Do you ever scratch or hit yourself? Do you ever hit your head when you get mad? How about other people – do you ever hit, scratch or kick them?
C. For children with MR ask the patient forthrightly if they are in special ed or special classes. If you have trouble obtaining a clear answer ask the following, “How many kids in your class? And how many teachers or aids?” Note that special classess often have a high teacher / aid to pupil ratio, like 10-12 kids and 3 teachers / aids.
For adults with MR ask if they work outside the house. Adults with mild MR often have jobs like baggers at grocery stores. Those with moderate MR may work in sheltered workshops, where they may package items, as for example, placing bolts or screws in bags for sale.
That’s it for today. If you have further tips or corrections you suggest, please email me.
“An early morning walk is a blessing for the entire day.” – Henry David Thoreau