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Children & AdolescentsMedical-Legal IME

By Kerry Mendes, M.D.

 

Child and Adolescent Independent Medical Examinations (IME)

Forensic vs. Clinical

Key Similarities and Differences

Psychiatric evaluation provides critical information for forensic examiners and clinical psychiatrists. However, content and context of each are different.

Not Interchangeable

Clinical and Forensic assessments serve different purposes that come with serious ethical and legal distinctions that matter when an expert witness is retained. This article describes these different medical assessments.

Mental Health of a Child or Teen

A comprehensive mental health examination is the keystone for the treating psychiatrist to form:

  • a clear clinical picture of a patient: e.g., acute, chronic and transient symptoms, overall health
  • formulate a diagnosis, and
  • develop a treatment plan.

In a forensic case the focus shifts

Medicolegal questions are addressed and answered, to help the Court and inform legal decisions. 

 

Elements of a Forensic IME

  • Interview with the child and parent/guardian and others with information or observations about the situation and person.
  • Includes topics and scope that may not be part of the clinical interview such as legal history.
  • Collateral information. The observations of “collateral informants” like parents, as well as records and reports that may suggest a line of questioning in the IME.
  • History-taking (developmental, medical, and family)
  • Behavioral observations by the forensic psychiatrist during the IME
  • Mental status examination (“MSE”)
  • Diagnosis
  • Treatment plan: Unlike the clinician,  an expert witness maybe asked to project a likely treatment plan to address damages, cost projection, and/or mitigation questions.
Purpose and Focus

Treatment and Recovery vs. Information for a Trier of Fact

Clinical Exam

A standard examination may take place when a parent expresses concern about a child’s behavior or thinking.1 The discussion often starts with a Pediatrician who may refer the patient to a psychiatrist for further assessment and treatment.

 

  • Assess and understand the child’s mental and emotional status. Diagnosis.

    A child psychiatrist establishes if there is a psychiatric condition, and diagnosis present in their patient.

  • Information-gathering.

    Treatment psychiatry, like Forensic Psychiatry, includes information-gathering to produce a clearer picture. E.g. interviews with family members, review of medical and school records, and communication with other providers. The singular goal is helping the patient get better. A provider may recommend Neuropsychological testing.

    Treating psychiatrists do not generally have the opportunity or time to review and integrate large amounts of collateral information into the evaluation and do not generally have access to legal documents or their patient’s attorney, nor is that their focus.

  • Alleviating symptoms. Treatment.

    Alleviating or eliminating the patient’s psychiatric symptoms is part of the treatment plan which might include a medication regimen, therapy, referrals to and conferring with other specialists.

  • Patient, parents and guardians.

    The “client” is the patient and/or their parent/guardian. This distinction is particularly important if there is a conflict between the parent and the minor about the diagnosis and treatment.

  • Medical notes.

    Clinical notes are usually brief, focusing on the patient’s diagnosis and treatment plan. They are primarily intended to be read by other clinicians and may contain clinical jargon and abbreviations that may not be understood by a layperson. 

Forensic Exam

A forensic psychiatric evaluation is performed for legal or court-related purposes.

  • Answer medicolegal questions.

    These are posed by the referrer, who may be an attorney or court. These are to provide an expert opinion to assist the legal proceedings.

  • Examinee is not a patient.

    The child being assessed is referred to as an examinee—not a patient, as the examiner is not a treating provider.

  • Diagnosis.

    On assessment, the forensic examiner may issue a diagnosis. They may also discuss, but not recommend, treatment to shed light on damages,  should liability be proven. Mitigation steps by the opposing party is considered if it improves the trajectory of recovery.

  • Forensic information-gathering.

    Forensic evaluators review a wider scope of information than treating providers. They will review clinical notes, and other medical records, as would the treating provider, but an attorney might provide additional documents that are not provided to a treater. They may suggest to an attorney obtaining neuropsychological testing, discussed below. 

  • Expanded scope of information sources.

  • The child’s medical and developmental records (perhaps all the way back to birth.)
  • School reports. E.g., sudden changes in a student’s performance, violent or disruptive behavior at school, suspension or detention especially if the timeline coincides with a traumatic event or behavior related to the legal questions.
  • Previous evaluations.
  • Child welfare, social worker records, CPS.
  • Juvenile justice system records, and any other relevant legal or medical documentation.The volume of information that examiners must review for a forensic evaluation can amount to hundreds or even thousands of pages.

Therapeutic relationship in treatment

If a treatment plan includes psychotherapy with a psychiatrist or psychologist, a therapeutic relationship exists between that psychiatrist and their patient.

The nature of the relationship is supportive and advocative.

 

No therapeutic relationship in a forensic examination

The relationship is impartial, objective, and evaluative. There is no therapeutic relationship formed between the examiner and examinee.

Examiner’s Expertise
Clinical

Psychiatrists are licensed physicians.

Child and Adolescent psychiatrists generally have additional residency training in treating children and adolescents.

Board-Certified Child and Adolescent Psychiatrists have completed an additional year of Fellowship training and rigorous examination.

Board-Certification in Child & Adolescent Psychiatry is not necessary to treat a young patient.

In some cases, a licensed Psychologist, trained Nurse Practitioner or Licensed Social Worker (LCSW) may conduct an exam for treatment purposes. 

Nurse Practitioners can prescribe medication, with state-by-state restrictions about controlled substances. Controlled substances include  certain medications that are used to treat anxiety or other psychiatric conditions. In 6 states, Psychologists may also prescribe medications. 

Unlike Nurse Practitioners, LCSWs are not qualified to assess medication, labs, imaging, or medical conditions, nor can they prescribe medication. 

Examiner’s Expertise
Forensic Expert Witness

A forensic Psychiatrist could be a psychiatrist who issues forensic findings or testifies. They may not have received specialization training or achieved Board-Certification in subspecialties like Child & Adolescent Psychiatry and Forensic Psychiatry. 

In both cases, the doctor has completed a year of dedicated Fellowship training and passed the Board examination for the respective subspecialty. This reflects about 10 years of medical and psychiatric training.

Forensic Psychiatry Fellowship programs are small and competitive: fewer than 2-4 Fellows in a given year offered at only 50 universities nationally. 

Forensic Psychiatry Fellowship includes conducting medicolegal assessments, caselaw, testimony and considerably more.

About 4% of all Board-Certified Psychiatrists are also Board-Certified in Forensic Psychiatry. Obviously, it is even rarer for psychiatrists to hold all 3 Board-Certifications. 

The Importance of Specialized Forensic Training

Fellowship in Forensic Psychiatry focuses on medicolegal implications for the psychiatrist examiner. For example:

      • How to integrate medical and non-medical documentation in light of a complicated legal question.
      • Concepts, terminology and legal implications, e.g., “Maximum medical improvement (MMI)” or “reasonable degree of medical certainty.”
      • Competency (criminal, guardianship, emancipation cases, fitness to stand trial.) The thresshold of legal competency in a child or adolescent is different than in an adult. Sentencing, for example, is significantly impacted.
      • Mastering the distinctions are reflected in the triple Board-Certifications described above, though some doctors acquire expertise through clinical exposure and experience.

Physician vs. Non-Physician

Courts may allow a forensic exam to be carried out by a specialist who is not a physician, e.g., a Board-Certified Forensic Psychologist, a trained Nurse Practitioner or LCSW. They do not all have the same training or thresshold for Board-Certification or licensing.

Due Diligence: Verify the Credentials of a Medical Expert Witness

Attorneys are wise to investigate any expert witness’ claim of training or licensing, and if the findings are within the confines of their licensing.

An expert may be disqualified.

Confirming credibility, or challenging it is a tool helpful to triers of fact in Direct or Cross-Examination. An expert testifying outside their lane may well strip its impact on jurors.

Imagine, for example, a non-physician opining about mental health where an examinee is taking cancer medications or struggling with a degenerative disease.

Attorney Resource: Verify Psychiatrist Board-Certification with the ABPN VerifyCert tool tool.

Conflicts of Interest
Treating psychiatrist serving as an Expert Witness

Ethical and professional conflicts may well exist if a treating psychiatrist testifies in a medicolegal matter. The objectivity required of a forensic examiner should not interfere with the advocative nature of a clinical relationship. In therapy the relationship or “therapeutic alliance” is between treater and patient only.

What Is The Therapeutic Alliance?

Bonds are constituted by the core conditions of therapy, the client’s attitude toward the therapist, and the therapist’s style of relating to the client; goals are the mutually negotiated, understood, agreed upon, and regularly reviewed aims of the therapy; and tasks are the activities carried out by both client and therapist.”2

Trust

To accomplish the goals of therapy, trust is crucial. That includes trusting that what you reveal to your doctor will be confidential and not be made public, except in the case of mandatory reporting laws. 

Legal Consequences

The moment a treating psychiatrist testifies on the stand as an expert witness there is the chance their testimony will negatively impact their patient.

The patient or their parent or guardian may lose their case, have to pay a large award, or receive les than they thought was fair. They may even be found guilty of a crime.

Consequences could include being placed in foster care or juvenile detention, or even prison if a minor is tried as an adult.

Family Dynamic

The family dynamic could change, even if the outcome is exactly as desired by the patient. The stakes are emotionally high. 

Broken Alliance – Broken Treatment

Whatever the outcome of a case, the therapeutic alliance is broken or changed and effective treatment may not be restoreable.

Therapist Expert Witness’ Conflict of Interest

A treating provider is not the appropriate expert witness.

Obligation to be Objective

The Forensic Psychiatrist has no therapeutic alliance and can render objective findings specific to the legal question. No patient relationship is harmed, no treatment impacted. The trier of fact is the beneficiary.

Collateral Information

What is “Collateral Information?”

Collateral simply means ‘secondary or subordinate’ information to be considered. It can flesh out a picture of the child or teen’s mental health and behavior.

This is especially important when the young examinee’s behavior reveals details they are unable to report directly during an IME. Developmental milestones exist for insight and perspective. Not all children hit those milestones, or do so at different ages. A collateral informant may be the best resource.

Who is a Collateral Informant?

“Informant” or “Collateral Informant” is a term of art that desecribe anyone ancillary to the examinee (child, teen or adult) who has observations or additional information not otherwise in the records. For example, parents or other family member, or a teacher for reasons described above.

Forensic Considerations

Unlike a treating doctor, the interview may acknowledge variations in motive or the  interactive dynamic among individuals relevant to the legal matter but not necessarily relevant to providing medical or psychological patient care.

High Stakes, Conflicting Stories, Information and Motive

The stakes in forensic cases can be critical, such as the custody of a child, criminal charges, or large amounts of money.

Examinees and collateral informants may attempt to manipulate or distort information and may exhibit more unconscious biases than in a clinical setting. 

Forensic psychiatrists are trained to carefully evaluate for the presence of these sorts of issues in a legal matter and receive additional training on how to mitigate their effect on the evaluation should they occur.

 

Imaging x-ray and MRI

Testing

A comprehensive child psychiatry evaluation may include

        • Standardized assessment tools such as age-appropriate screening tests or rating scales to provide insight into the child’s symptoms and their severity.
        • Lab Tests or imaging to rule out medical causes for symptoms.
        • A psychiatrist may also refer the child for multidisciplinary assessment by a neuropsychologist or speech-language pathologist.
Standardized Neuropsychological Tests

Standardized psychological tests are backed by research and can serve as objective sources of information which are difficult to assess or document through interaction with the patient alone, such as malingering (lying about or exaggerating symptoms), suboptimal effort, undue influence, or risk of future violence.

Training and Experience

Training and experience are vital when using testing instruments in assessments, as errors in administration or interpretation of tests can produce incorrect information and conclusions.

Forensic psychiatrists receive training on how to use these tools including the neuropsychologist’s findings, and how to interpret their results and incorporate them into the forensic psychiatrist’s conclusions.

Conclusion

Related But Distinct Disciplines

Treatment and forensic psychiatry are two related but distinct disciplines. While both types of evaluations involve assessing a child’s mental health, they differ in purpose, focus, and outcome—as well as the examiner’s training and expertise.

Legal Context and Specialized Skills

Child psychiatric IMEs require examiners with expertise in not only child and adolescent mental health but also in how mental health interacts with the legal system.

This specialized skillset is critical, as misinterpretation of legal concepts or assessment tools can negatively affect a forensic evaluation just as much as misinterpreting medical symptoms or concepts can affect a treatment evaluation. When we exclude medical information, a forensic child psychologist may also be qualified to render limited findings.

Forensic Child Psychiatrists

Forensic child psychiatrists are uniquely positioned to undertake medicolegal evaluations due to their specific training that enables them to address legal questions, critically evaluate multiple and conflicting information sources, administer and interpret testing tools, and render a medical opinion that assists the Court.

1. In the case of adolescents, they may have certain legal rights to manage their own healthcare, or participate in a forensic IME if they are legally emancipated. Also, in some states certain health care issues, like birth control, or even general care, can be raised by an adolescent over a thresshold age. 

2. “Therapeutic Alliance” definition, APA Dictionary of Psychology, https://dictionary.apa.org/therapeutic-alliance