The Social
Security Psychiatric Disability Evaluation
Basic
Skills Workshop, 2002 Annual Meeting, San Diego
January
18, 2002
Copyright
2002 C. Donald Williams MD CGP
Background
Congress
assigned the Social Security Administration (SSA) the responsibility for
evaluating applications for Social Security Disability Insurance, or SSDI.
The SSA contracts with state agencies—called Disability Determination
Services (DDS) in each state throughout the nation and Puerto Rico to perform
these services. SSA’s
headquarters are located in Baltimore, and oversees operations through ten
regional offices. The
Social Security Act provides for benefits to be provided for the disabled that
meet certain criteria. Whereas
welfare benefits are based on financial need, SSDI benefits are granted on the
basis of “impairments”, which are defined in the Social Security Act.
SSDI is program for those who have paid into the system (FICA) and
earned “quarters of coverage”. SSI is a needs based program (like welfare).
Both programs require that individuals must meet certain medical
criteria to be allowed. These criteria include the anticipated length of the
disability and a set of accepted medical conditions causing impairments that
may result in disability. They also provide a definition of the degree of
functional impairment in several spheres of functioning that set the threshold
that must be met in order for a person to be entitled to disability benefits.
The law defines disability as the inability to engage in substantial gainful
activity by reason of a medically determinable impairment which can be
expected to result in death or which has lasted or can be expected to last for
12 continuous months. The
disability program looks at a claimant’s remaining functional capacity to
perform any type of work in the national economy.
If a claimant disagrees with the initial medical disability decision
he/she can file for reconsideration. If
still dissatisfied, he/she can appeal to the Administrative Law Judge and
request a hearing.
Why
do Social Security Disability Evaluations?
There
are several advantages to conducting regular Social Security Disability
Evaluations.
·
They
offer concentrated practice in conducting efficient assessments of a
relatively wide variety of patients
·
They
present an opportunity to refine conceptualization, writing and dictation
skills
·
They
are an effective way of filling gaps in a schedule with guaranteed payment
·
They
can serve as an entrée to becoming involved in other types of psychiatric
disability evaluations because of contact they afford with the legal community
·
They
present an opportunity to provide quality professional services within the
public sector with few of the problems or difficulties often associated with
such work.
Procedural
Matters
The
Social Security Administration contracts with physicians to perform
evaluations of individuals who have applied for benefits.
Psychiatric evaluations are requested whenever the examiner (an
employee of the Disability Determination Services) finds that psychiatric condition may be present or there is
insufficient information for a complete disability decision. Social Security Hearings Administrative Law Judges (ALJ)
may also order psychiatric evaluations at their discretion after hearing
evidence presented at an appeal hearing.
Compensability requires total disability, i.e. the inability to perform
the functions of any job, for a period of at least 12 continuous months.
SSDI
benefits consist of cash benefits, which are typically greater than public
assistance (welfare) benefits. Medical
benefits in the form of Medicare are added after a defined period of
disability.
Some
applicants are denied benefits in their initial application.
Some
statistics are as follows: Fiscal
Year 99 (Oct 98-Sept 99) National average of initial case allowances=37.3%.
FY 2000 (Oct 99-Sept 00) = 38.2%.
For the Seattle Region, 42.7 % and 40.5 %, and for Washington DDS, 42.9
% and 42.1% respectively.
Applicants
may request a reconsideration of the initial denial, and if that is
unsuccessful they may demand a hearing by a Social Security Hearings Judge (ALJ).
No attorneys are involved in the first step, occasionally an attorney
is retained for the reconsideration phase, and the applicant typically retains
an attorney for the formal hearing before a judge.
Attorney fees are set by statute, and the Social Security
Administration must specifically approve attorneys before they can represent
clients.
In
Washington State, the psychiatrist-evaluator is paid a nominal fee (about $30)
for record review if the applicant fails to appear for the appointment.
Missed appointments must be reported to the Social Security scheduling
office within 24 hours. This amount varies from state to state.
Some states pay nothing, while some states pay $10-25.
Some states are under state law to follow their “parent agency” fee
schedules, which means compensation for no shows or record review could be
considerably higher. Payment
for extra forms and review of excess medical also varies greatly from state to
state. The best advise to those
interested in doing evaluations would be to contact the state agency (DDS) to
find out their reimbursement rates. The SSA does not expect physicians to
reschedule a claimant that has missed an appointment. An additional fee is
paid if the medical file to be reviewed is 25 pages or longer. If additional
forms are requested, separate fees are paid for their completion.
The
Psychiatric Evaluation
A psychiatric evaluation consists
of a review of medical records provided by the DDS, a face-to-face psychiatric
evaluation of the applicant and the provision of a written report. The report follows a standard psychiatric evaluation format,
with particular attention to several routine questions that should be
addressed in the Summary and Discussion section of the written report.
The Disability Determination Services usually provides a suggested
outline (a copy is provided in your course material). The outline for
child psychiatric evaluations is more complex, but straightforward for those
with child training (a copy is
attached in the course material). The SSA is interested in facts and
evidence based conclusions as they bear upon impairments of specific
functional capabilities that have an impact on disability. Specific
observation and reporting of the claimant’s Activities of Daily Living,
along with relevant psychiatric history, and a fact based Mental Status
Examination are crucial to the exam’s utility.
Particular emphasis is placed upon utilization of the DSM-IV, as that
provides a more uniform basis for application of the relevant statues.
Occasionally,
you will be asked to complete the Psychiatric Review Technique Form
SSA-2506-BK (9-2000), either by an Administrative Law judge or by an
attorney representing a claimant. I
have included a copy of the current form for your reference. Although you
will not routinely be asked to complete it, familiarity with its provisions
will help you to understand the listings requirements and the information the
examiner must have to act on your report when it is received. A former
requirement that ALJ’s use the form in cases at that level of review has
been eliminated, although they are still required to use what is termed “Psychiatric
Technique” in explaining their rulings.
In general the ALJ’s are required to develop the evidence.
The ALJ’s are given discretion to adjourn, postpone, or reopen the
hearing at any time to develop further evidence before a ruling is issued.
For
our purposes it will be useful to describe elements of the form to reinforce
the importance of you (as the evaluating psychiatrist) providing data to
support conclusions in the evaluations conducted for SSA, and not simply
diagnostic conclusions based on a vaguely stated history and sketchy mental
status examination. This form
(developed in 1990, and as noted below modified effective September 20, 2000)
contains several sections, the most important of which describes symptoms or
behaviors to be checked as present or absent for the following categories of
disorders. The 12.XX numbers represent the “category” of the
disorder.
1.
12.02 Organic Mental Disorders
2.
12.03 Schizophrenic, Paranoid and other Psychotic Disorders
3.
12.04 Affective Disorders
4.
12.05 Mental Retardation and Autism
5.
12.06 Anxiety Related Disorders
6.
12.07 Somatoform Disorders
7.
12.08 Personality Disorders
8.
12.09
Substance Addiction Disorders
9.
12.10
Autism and Other Pervasive Developmental Disorders
Each
of these categories is provided with a specific set of criteria by which its
absence or presence is judged.
For
example, for 12.03 the test is:
“Psychotic
features and deterioration that are persistent (continuous or intermittent),
as evidenced by at least one of the following:
1)
Delusions or hallucinations
2)
Catatonic or other grossly disorganized behavior
3)
Incoherence,
loosening of associations, illogical thinking, or poverty of content of speech
if associated with one of the following;
a.
Blunt affect, or
b.
Flat affect, or
c: Inappropriate
affect.
You
have a copy of the SSA form for reference and review purposes.
In general, the criteria correspond fairly closely to the DSM-IV
criteria for the listed conditions.
Beginning
with September 20, 2000 an additional qualifier was allowed for each condition—“A
medically determinable impairment is present that does not precisely satisfy
the diagnostic criteria above. Pertinent symptoms, signs, and laboratory finding that
substantiate the presence of the impairment”.
The modified “Disorder” must be listed. Based on the presence or
absence of findings in the above categories, the SSA examiner is then asked to
rate the severity of impairment, describing the degree of functional
limitation in four areas of functioning.
(When a psychiatrist is asked by an attorney to conduct an evaluation
for an Appeal Hearing, he/she may be asked to complete the form and the
ratings.)
Significant
modifications in the “B” criteria
were introduced effective September 20, 2000, and are reflected in the
following description:
1.
Restriction of Activities of Daily Living
2.
Difficulty in Maintaining Social Functioning
3.
Deficiencies
of Concentration, Persistence or Pace; [deleting “resulting in Failure to
Complete Tasks in a Timely Manner” effective Sept. 20, 2000]
4.
Episodes
of Decompensation, each of extended duration. [This was modified to eliminate
“deterioration in work or work-like settings”.]
To
satisfy the listings requirements,
the impairment must be at least “marked” or greater in two or more of the
four areas of functional limitation. [This was modified to standardize the
necessary number of “B” criteria from 3 to 2 for Somatoform Disorders and
Personality Disorders.] An
extreme rating on any of the first 3 criteria will satisfy the listings
requirements, as will a rating of “4 or more” for criterion 4.
There
are specific guidelines to be followed by the SSA in reviewing these forms.
For example, “repeated episodes of Decompensation” is defined as
meaning “three episodes within one year, or an average of once every four
months, each lasting for at least 2 weeks.”
If the episodes are more frequent but briefer, or less frequent but
longer, the adjudicator is required to use judgment to determine whether the
functional effects are comparable to those set forth in the listings.
“C”
criteria
for chronic disorders are now included in the Listings 12.02
Organic Mental Disorders, 12.04 Affective Disorders, in addition to 12.03
Schizophrenia. The “C”
criteria are considered if the “B” criteria are not met.
This modification was effected because of the realization that an
additional test of functional limitation was necessary for conditions that
tend to be chronic and disabling, but that might not meet the severity
requirements of the “B” criteria. Documentation
must show a chronic disorder of at least two years’ duration that has caused
“more than minimal limitation of ability to do basic work activities.”
An inability to function outside a highly supportive living arrangement
need only have lasted one year, reduced from two years.
A third “C” criterion has
been added addressing individuals who are marginally adjusted and for whom an
even minimal increase in mental demands or change would be predicted to cause
the individual to decompensate.
The
“Mental Residual Functional Capacity
Assessment” (Form SSA-4734-F4-SUP) is a measure of the claimant’s
ability to perform functions necessary to employment.
Each mental activity is to be evaluated within the context of the
individual’s capacity to sustain that activity over a normal workday and
workweek, on an ongoing basis.
The
general areas are titled:
A.
Understanding and Memory (3 measures)
B.
Sustained Concentration and Persistence (8 measures)
C.
Social Interactions (5 measures)
D.
Adaptation (4 measures)
The
social security examiner may request this form, as may a hearings judge, or an
attorney representing the applicant at the hearings stage of the appeal
process.
Conduct
of the evaluation
The
purpose of the psychiatric evaluation should be explained to the claimant.
The examinee should be advised of the limitations on confidentiality
associated with their status as an applicant for SSDI.
They should be advised that the interview is for evaluation purposes
only, and that it is not for treatment. They should be informed that a copy of
the evaluation would be provided to the Social Security Administration. My
practice is to suggest that the applicants themselves directly request that
the SSA provide copies of the evaluation to any other parties they wish to
receive the report. This avoids the possibility of violating confidentiality
guidelines or overlooking the obtaining of release of information forms. As a
matter of policy, the physician evaluator is allowed to directly furnish a
copy of the evaluation to a treating physician. Nevertheless I prefer to have
the patient assume responsibility for requesting the report be sent from the
SSA to other parties.
Although
in the past the SSA provided phone-in transcription service to an 800 number,
in Washington State psychiatrists have been required to provide their own
transcription for the last several years because of funding constraints,
making on-site transcription services an economic necessity if any significant
work volume is undertaken . This
varies from state to state; many states still provide dictation/transcription
services.
Conduct
the examination according to a standard format provided by the DDS.
I find it helpful to use a form I have developed with my word
processor, as that speeds the transcription process and helps me to remember
all necessary areas of inquiry. I have included a copy of my headings in the handouts.
Record
primary data, including liberal use of quotes, accumulated during the
evaluation. State the specific
findings on the mental status examination directly.
Avoid statements such as “concentration and memory are grossly normal”
in favor of facts. As an example:
“The patient was able to recall three out of three dissimilar objects at 5
minutes and was able to repeat 7 digits forward and 5 digits backward”.
I utilize a prepared evaluation format, which helps to avoid omissions.
The evaluation should be dictated, as it is possible to produce a meaningful
4-6-page report within 5 or 10 minutes given sufficient practice and
experience. For transcription
purposes, I developed a formatted word processing file that contains relevant
headings and saves a significant amount of typist time.
One proofreading is all that should be necessary. This makes it
possible to conduct the evaluation and issue a report within 24 hours.
The SSA appreciates timeliness, and I find that I am more efficient
when the material is fresh in my mind. I
make it a practice to dictate all social security evaluations within 24 hours
of the interview. Usually they
are completed during breaks between patients within an hour or two of seeing
the patient, markedly reducing the subjective sense of being burdened.
In other words, don’t let dictation pile up.
Finally,
a Social Security Disability Psychiatric Evaluation must offer diagnoses
utilizing the DSM-IV format, and comment on the degree and duration of
functional limitation resulting from the diagnosed condition. These requests
are made explicit in the evaluation request.
Avoid offering diagnoses of mental retardation in the absence of formal
psychological testing, and if you correctly place such diagnoses on Axis II.
Provide
an evaluation of the claimant’s ability to manage his or her own funds, as
this will determine whether or not a representative payee is named if benefits
are awarded. Include an opinion
regarding the prognosis of the condition with treatment, and an opinion
concerning the necessary length of psychiatric treatment.
Summary
of Main Points:
1.
Obtain Informed consent; explain the purpose of the evaluation, and how
the information will be distributed. Treat
claimants courteously. You are a neutral professional, and you are not an
adjudicator.
2.
Conduct a standard psychiatric evaluation utilizing the DDS guidelines.
Record the primary data you obtain in the evaluation, not just your
conclusions. Your opinion must be
supported by facts and evidence to be given weight by the examiner or by an
ALJ.
3.
Employ DSM-IV diagnostic criteria in your diagnosis section.
4. Specifically
answer the examiner’s questions regarding the claimant’s prognosis with
treatment, and the ability to manage his/her own funds.
5. Provide your report
promptly to DDS.
6. If
you for any reason feel that it would be unsafe for you to begin or continue
an evaluation, cancel it, and notify DDS of your reasons.
It may be necessary for the evaluation to take place within a secure
facility.
Acknowledgement: Leann Amstutz, Professional Relations Specialist, Washington
Disability Determination Services, Olympia, WA kindly reviewed this
presentation and offered valuable corrections as well as a national
perspective. All errors and
omissions are of course my responsibility.
*****************************************************
Adult Social
Security Disability Eval Example—No
Diagnoses—V71.09
KYLENE
M. BARGE
SSN:
xxx-xx-xxxx
D.O.B.:
03/14/1978
Identifying
Data:
The
claimant is a 22-year old single Caucasian female who lives with her fiancé.
Statement
of Non-Confidentiality:
The
claimant was advised that this interview was for evaluation purposes only and
that a copy of the evaluation report would be provided to the Social Security
Administration. The claimant was further advised that no doctor-patient
relationship was established and claimant agreed to continue with this
evaluation with that understanding.
Chief
Complaint:
“My
pain.”
Records
Reviewed:
A
referral consultation by Dr. Grissom, Pain Management Center in Lewiston,
Idaho, was reviewed. He presents
a history of a motor vehicle accident and care subsequent to that accident.
He essentially notes the development of pain cycles lasting about eight
weeks. Mood fluctuations
associated with pain are noted. Fluctuations
in sleep patterns and relationships with relatives and co-workers are noted.
Fibromyalgia was noted as the primary diagnosis and was apparently
documented through a workup at the University of Washington.
History
of Current Situation:
The
claimant stated that her pain began subsequent to a motor vehicle accident
that occurred in about October 1996. She
was leaving school, driving down the street, stopped for a car that slammed on
its brakes in front of her, and was rear-ended by a car following her. She was taken to the hospital by ambulance, placed in a neck
collar for about one week and then saw numerous physicians, as outlined in Dr.
Grissom’s referral. She has
received numerous medications and has also received physical therapy.
She stated that she has had difficulty holding down a job.
However, she was able to hold a job as a bank teller from January 1998
through May 1999, about 18 months. She
attributes her longevity at that position to her ability to move around, sit
and stand, and not have to remain in one position.
Other
jobs as a cashier and a secretarial position lasted for briefer periods of
time because of the inability to shift and change positions.
Over
the past three months she has done “nothing”.
“I’ve just been hanging out – developing a plan for school”.
She stated that she plans on completing her schooling and receiving an
AA degree and then going to work in criminal justice.
Her
sleep continues to be disrupted, depending on the stage of her pain cycle
noted above. She falls asleep
anywhere between 9:00 p.m. and 5:00 a.m. and arises anywhere between 5:00 a.m.
and 10:00 p.m. Her energy level
is low. She has rare crying
spells. Her temper is good.
Her concentration is excellent as is her memory.
She does not think of death. Her
appetite is within normal limits. She
gained 35 pounds while taking Amitriptyline last fall.
She has resumed exercising, walks every day, and notes that she feels
better since having done that.
She
receives no financial benefits.
Employment
History:
She
worked most recently as a cashier for four weeks and prior to that she worked
as a secretary for about three months. Prior
to that time she worked for 18 months as a teller at Seafirst Bank.
That was her best job.
Current
Medications:
1)
Vicodin
2)
Flexeril
3)
Ambien
She
noted that she was taking Effexor and Nortriptyline, but ran out of these
medications and since having instituted exercise, is now feeling better
without them
Past
Personal Psychiatric History:
Hospitalizations:
She was hospitalized in 1993 at about the age of 13 when her
parents were going through a divorce. This
was an overnight hospitalization only and she reports that she had been having
suicidal thoughts. She had some
follow-up counseling, which was helpful.
She stated that that had resolved the matter.
Psychiatric
Outpatient Treatment: Currently
she and her fiancé are receiving premarital counseling through her pastor.
Outpatient counseling received prior to that time – at the time of
her parents’ divorce was helpful.
Family
Psychiatric History:
A
grandfather has a history of depression and another grandfather has a problem
with alcohol.
Past
Medical History:
Fibromyalgia
Developmental
History:
She
was born and raised in Walla Walla, Washington.
Her father worked as a trucker and her mother works as an RN. Her parents divorced when she was 13-years old.
She has a good relationship with both her mother and father, by her
report.
She
has one older brother.
She
stated that she was rebellious when starting high school and instead went to
Running Start, a program through the local community college.
She ultimately attained her diploma.
She began very successfully academically, then began to fail classes
but has now improved her GPA to 3.2.
She
has best friends and sees them.
Her
hobbies include riding horses and crocheting.
There
is no history of military service.
Typical
Day:
Her day follows a variable schedule as noted above in the earlier portion
of the evaluation.
She
prepares occasional meals, does much of the laundry and housecleaning, and
shares financial management responsibilities with her fiancé.
Alcohol
and Substance Use:
She states that she consumes one beer per week, does not smoke cigarettes,
and does not use street drugs. She
has used marijuana in the past to assist with pain relief, according the
medical reports. This is a
relatively well-known phenomenon and appears credible.
Legal:
She
was arrested for shoplifting at age 18. This
matter is now resolved.
Mental
Status Examination:
The
claimant presented as an overweight but friendly woman who was neatly attired
and cooperative throughout the evaluation.
Her vocabulary and grammatical structure was about average.
She stated that she had no suicidal ideation and there was no evidence
of homicidal ideation.
There
was no evidence of psychotic thought processes and she specifically denied
auditory and visual hallucinations and denied possessing special powers or
abilities as well as denying paranoid ideation.
She
was oriented to the date and knew the name of the last two Presidents.
She was quickly and correctly able to perform serial three subtractions
and subtract $.45 from $1. She
was able to recall three out of three dissimilar objects at five minutes.
Her
fund of knowledge was good for a person of her education and background; she
knew the names of the south and east bordering states as well as the largest
city and the capital city of the state of Washington.
She was able to quickly and correctly spell the word “world”
forward and backward and was likewise capable of simple abstraction.
The proverb “spilled milk” revealing “don’t dwell on your
mistakes”. If she were to find
a stamped and addressed envelope on a sidewalk, she would take it to the post
office, revealing intact judgment in simple non-emotionally loaded situations. She was also able to easily and correctly repeat seven digits
forward, a good performance.
Summary
and Discussion:
This
individual presents with a prior history of depression, motor vehicle
accident, and a diagnosis of fibromyalgia.
However, she does not currently appear to be depressed, although
unquestionably at times of markedly increased pain, she would suffer from a
mood disturbance.
It
is to be noted that she has worked for periods as long as 18 months in
positions that allowed for reasonable accommodation.
Her
activities during a typical day are only mildly restricted and she appears to
have a normal range of interests. Her
ability to relate to other people is unimpaired.
Her ability to care for her personal needs and manage her own funds is
quite intact.
The
pastoral counseling she is receiving on a premarital basis is certainly
appropriate but is unrelated to her fibromyalgia or history of depression.
I
do not currently note the presence of any psychiatric diagnosis.
It is extremely encouraging that she does not appear to have any of the
cognitive problems typically associated with fibromyalgia, as that reflects a
very favorable prognosis for her, both with regard to her schooling and her
longer-term employment.
Diagnoses:
AXIS
I:
No diagnosis V71.09
AXIS
II: No diagnosis V71.09
AXIS
III:
Fibromyalgia
AXIS
IV:
PSYCHOSOCIAL AND ENVIRONMENTAL FACTORS: chronic
medical condition
AXIS
V:
GAF – 70
*****************************************************************************************
Child
Social Security Disability Evaluation Example
A Psychiatric Evaluation
RODNEY
HARRIS
SSN:xxx-xx-xxxx
D.O.B.:
02/10/xx
Identifying
Data:
Rodney
is an 8-year old boy who lives with his grandmother.
His 7-year old sister also lives at the same residence.
He attends Barge Elementary School.
He has lived with his grandmother for about five years.
Statement
of Non-Confidentiality:
The
claimant was advised that this interview was for evaluation purposes only and
that a copy of the evaluation report would be provided to the Social Security
Administration. The claimant was further advised that no doctor-patient
relationship was established and claimant agreed to continue with this
evaluation with that understanding.
Chief
Complaint:
“My
father – I just don’t like him because of his past.”
Records
Reviewed:
A
Psychiatric Evaluation conducted by this evaluator on this same boy dated
August 13, 1997 was reviewed. At that time I diagnosed an Attention Deficit Hyperactivity
Disorder, predominantly hyperactive impulsive type, on Axis I, along with
Conduct Disorders. I assigned a
GAF of 35-40 at that time. I
noted that he had come from a very abusive situation and that he seemed to be
functioning at a significantly deficient level.
A history of extremely serious physical abuse and neglect was also
noted.
History
of Current Situation:
The entire
interview was conducted was conducted with Rodney and his grandmother present.
Rodney
and his grandmother stated that he was a student at Barge Elementary School.
His teacher is a Ms. Glaspy. Rodney
then volunteered “I don’t like my father – he has a very bad past – I
like living at my grandmother’s.” He
stated that his father was living with his grandfather.
Rodney’s grandmother stated that his father had been released from
jail in about July of this year following six years of incarceration.
Initially,
Rodney stated that he had only one contact with his father but his grandmother
stated “honesty – more than that Rodney”.
He then reviewed some of his other contacts, 2-3 in number, including
Halloween and visiting with him briefly at a soccer game.
Regarding
his relationship with his teacher and authority figures, he stated that his
teacher was “very nice – very disciplined too”.
He volunteered that there were 24 students in the class.
He stated that he got along with his sister “like a brother and
sister."
He
stated that presently he had no real problems except “nobody gives me
trouble, except when I whine”. His
grandmother took some issue with that. She
noted that, although he had improved considerably in his behavior since he
first moved with her, that there continued to be arguments with his sister,
problems with his temper, and when he is visiting cousins “they are at each
other’s throat."
Rodney
sleeps about 8-9 hours per night. His
appetite is good. He is having
considerable success remaining on task. He
described his grandmother as “my best friend”.
They were physically close throughout the evaluation and she frequently
touched him in an affectionate manner.
There
have been no fights at school since the beginning of the second grade, a
little more than one year ago. His
energy level is satisfactory. He
has only a few friends, and only very occasionally will see them outside of
school.
Rodney
has no contact with his mother who has effectively abandoned him.
She is still using alcohol and drugs.
Employment
History:
Not
applicable.
Current
Medications:
Rodney
is taking no medication.
Past
Personal Psychiatric History:
Hospitalizations:
None
Psychiatric
Outpatient Treatment: Rodney has
been meeting with the same therapist at Central Washington Comprehensive
Mental Health every two weeks since about age 4, four or more years ago.
This has been very helpful.
Family
Psychiatric History:
Rodney’s
father is a convicted pedophile. He
was jailed for six years. He was
recently released.
Both
Rodney’s parents have had alcohol and drug problems.
According to Rodney’s grandmother, to the best of her knowledge
Rodney’s father is now clean and sober.
Past
Medical History:
Rodney has a
congenital hip dysplasia problem. He
has recently had to resume exercises for his hips because they have started to
give him trouble again. He has
problems with wheezing; there is a possibility of asthma. He will be going to Shriner’s Hospital in Spokane to be
fitted for a brace. His
grandmother noted that he was born with Cerebral Palsy.
Developmental
History:
Rodney
was born and raised in Yakima. He
was raised in an extremely abusive and neglectful environment for the first
four years of his life. He has lived with his grandmother for about the last five
years.
His
grandmother stated that since the time of the prior evaluation, she has been
involved in some legal battle with the mother regarding custody.
However, she stated that when she agreed to drop her requirement for
child support, that his mother dropped the case.
It is her conclusion that the mother was concerned only for financial
reasons.
Rodney’s
father has a paternal right to see Rodney and this represents a concern to the
grandmother. Rodney is uncomfortable with his father.
Rodney
is in a regular classroom. Rodney
and his grandmother both describe him as being a very good reader and
satisfactory in math.
Typical
Day:
Rodney
gets up at 7:30 and goes to school. He
is responsible for showering, brushing his teeth, and getting dressed.
He does this essentially without prompting and is able to do so in a
timely fashion. He has some
household chore responsibilities, including taking care of the dog, taking out
the garbage, and helping with yard work.
His
social functioning is generally pretty good with teachers and other adults.
It is more mixed with family and peers, although Rodney gets along very
well with his grandmother. Rodney
has recently become involved in a church group.
This appears to be a serious undertaking for him as he talked about it
at some length. He has no sports
activities.
Rodney
is able to concentrate for long periods of time on the computer. He
likes to read. He is able to
finish his tasks in a timely manner.
Alcohol
and Substance Use:
None.
Legal:
None.
Mental
Status Examination:
Rodney
presented as a friendly and forthcoming boy who appeared rather anxious.
His vocabulary and grammatical structure were about average.
He was a bit stiff. There
was some spontaneity.
There
is no evidence of suicidal ideation. He
used to have visions of dead people, but he describes them as good people, “not
like ghosts, more like angels”. He
views these visitations as coming from God.
He
states that even now on trips, he will imagine spirits or angels traveling
with him. This helps to pass the
time. He talked about feeling
like they touched him and he touched them.
He
was well groomed. He was wearing
appropriate clothing for the weather. He
had a normal gait, and his general motor movements were certainly within
normal limits. He was somewhat
more active than normal, but this appeared to be more anxiety.
He was cooperative, made eye contact, and although anxious regarding
his contact with me, was able to be adequately responsive.
His
mood is best described as anxious. There
was nor particular evidence of depression.
He got up and looked out the window on several occasions, although far
less frequently than at the time of my evaluation three years ago.
He
has imaginary friends, including Pokemon characters.
There also appear to be angels that he views as imaginary and
intentional friends.
Both
his expressive and receptive language were within normal limits.
The complexity was age-appropriate.
All of his speech was intelligible and he demonstrated good
articulation. There was no evidence of hearing or listening problems.
He
was oriented to the date. He knew
the name of the current and preceding President, rather remarkable for his
age.
He
had difficulty with counting backward by threes from 10.
10-6-3-0. He had to think
for some time to make this response. He
was able to follow a two-step command. He
had no difficulty following conversation.
He was able to volunteer information when I was speaking with his
grandmother. He displayed mild
distractibility. His length of
attention on specific tasks in the interview was about 3-4 minutes duration
but he would come back to the task without nearly the degree of intervention
that was required previously. His
judgment is quite limited but probably within normal limits for a child of his
age.
Summary
and Discussion:
This
boy has fortunately made considerable improvement since the date of my prior
evaluation. He continues to have considerable anxiety and certainly was
very traumatized by his developmental history.
Continued
therapy through the mental health center is absolutely critical to his
continued progress.
His
ability to concentrate, persist in a task, and maintain pace with work has
certainly improved since the time of the prior evaluation, although it is
still less than desirable. He remains very vulnerable to relapse.
Diagnoses:
AXIS
I:
1) Attention Deficit
Hyperactivity Disorder DSM IV 314.01 – resolved
2)
Dysthymic
Disorder DSM IV 300.4, childhood onset type
AXIS
II: No diagnosis V71.09
AXIS
III:
Orthopedic deformity
AXIS
IV:
PSYCHOSOCIAL AND ENVIRONMENTAL FACTORS:
separation
from parents
AXIS
V: GAF – 65
******************************************************************************************************************************************
Social Security Disability Evaluation—Private
Attorney Request
Tom Gerard, Attorney
Gerard Law Offices
P.O. Box 2730
Bellingham, Washington 9------
RE:
MILDRED CLINTON
Date of Evaluation: 06/12/00
SSN: xxx-xx-xxxx
D.O.B.: 8/5/67
Dear Mr. Gerard:
Thank you for allowing me the opportunity to perform a
psychiatric evaluation on Mildred Clinton.
The text of the psychiatric evaluation follows.
Identifying Data:
Ms.
Clinton is a 32-year old married Caucasian female who lives with her spouse
and 14-year old daughter; they currently reside in a motel, having recently
had to move from their residence.
Statement of Non-Confidentiality:
Ms.
Clinton was informed that this evaluation was being conducted at the request
of her attorney, Mr. Thomas Gerard and that a copy of the evaluation would be
furnished to him. She agreed to
proceed with the evaluation with this understanding.
She was further advised that this was for evaluation purposes only and
that no doctor-patient relationship was established.
Chief Complaint:
“I
am still battling my depression – I have two weeks of really bad attitude
– just craziness – throwing things – and packing my things – I didn’t
know where I was going.”
Records Reviewed:
1) A
02/28/98 brief Adult Intake Evaluation from Western Washington Comprehensive
Mental Health was reviewed. This
handwritten evaluation noted impaired memory, suicidal thoughts, a diagnosis
of Bi-Polar Disorder, depressed type, and a deferred diagnosis on Axis II.
A GAF of 45 was awarded. It
was noted in the evaluation that bi-polar episodes had occurred since age
15-16.
2)
A
03/02/98 Psychiatric Evaluation by Dr. Ackerly, psychiatrist at Western
Washington Comprehensive Mental Health is noted.
Dr. Ackerly notes a history of her having been treated for her bi-polar
disorder with Lithium, Prozac, and other medications.
Again psychological problems are noted since her teenage years.
Running away from home and a teenage pregnancy are noted, along with
drug use between ages 16-19. Drug
abuse included LSD, marijuana, speed, crank, and alcohol.
A pattern of rapid mood swings lasting 2-5 hours interspersed with
suicide attempts, including wrist slashing and overdosing in response to life
stressors, are noted. An episode
of sexual abuse is noted at age 5-6 and a rape episode at age 18.
Problems in school are noted. In
the Summary and Discussion portion of the evaluation, Dr. Ackerly noted
multiple substance abuse, and a possible history of borderline personality
disorder, and posttraumatic stress disorder.
Episodes of depression are noted.
He stated that she did not present any family history of psychiatric
illness (in contrast to the history presented to this evaluator).
3)
A
04/19/98 Discharge Summary from Bellingham Valley Memorial Hospital, Inpatient
Psychiatric Unit, is noted wherein diagnoses of Major Depression,
Polysubstance Abuse, and Personality Disorder are given.
Admission diagnoses from the same date are the same.
4)
