In the same year that DSM-III was published (American Psychiatric Association, 1980
), Julius Richmond, then Surgeon General in the President Carter Administration, reported on the remarkable achievements in addressing the needs of citizens with intellectual and developmental disability (ID/DD) in the United States. Major advances had begun in the preceding two decades, beginning in 1961 with the establishment of the President’s Panel on Mental Retardation by President Kennedy at the urging of his sister Eunice Kennedy Shriver. Subsequent benchmark legislation in 1963 led to a further impetus for development of a national plan and programs to fight ID. Richmond observed, “For the first time in our history, the Federal government committed the resources of the nation on a large scale to enhancing the well-being of some of its least fortunate citizens”
(Szymanski, Tanguay, 1980
In the intervening 50 years, there has been a dramatic amelioration of the life circumstances of persons with ID/DD in the United States, with improvements in inclusionary education, assisted employment, housing, and recreational opportunities. The National Association for Persons with Developmental Disabilities and Mental Health Needs (NADD), established in 1983, has provided a national and international forum for mental health professionals to exchange evidence-based knowledge on mental health issues. NADD has also recently published a Diagnostic Manual on Intellectual Disability (DM-ID) (Fletcher, Loschen, Stavrakaki, First, 2007
) with involvement of key leaders worldwide in order to disseminate more accurate DSM-IV-TR (American Psychiatric Association, 2004) diagnoses in persons with ID/DD. Despite these achievements, mainstream interest among psychiatrists in the United States has remained low. For optimal care of persons with ID/DD, psychiatrists need to contribute as members of interdisciplinary teams and dissemination of knowledge in the training of mental health professionals is of paramount importance (Bouras, 1999
). Through specific committees, both the American Psychiatric Association (APA) and the American Association of Child and Adolescent Psychiatry (AACAP) have regularly published assessment guidelines and evidence-based practice parameters for the care of persons with ID/DD. There is therefore recognition of the duty of psychiatrists to respond to the mental health needs of persons with ID/DD. There is also consensus on the lack of training in ID/DD. Almost 20 years ago, an important APA Task Force on Psychiatric Services to Adult Mentally Retarded and Developmentally Delayed (1991) had also underscored the shift in care from institutions and the importance of training psychiatrists to address the needs of persons with ID/DD in their community. Nevertheless, the status of practice, training and research in psychiatry of ID/DD remains unplanned, especially compared with the current situation in the UK, Ireland, Canada and Australia, each with formal Sections on Psychiatry of ID/DD with credentialing requirements for subspecialty training and regionalized community care.
The existence of separate service structures in mental health and ID/DD in the United States presents important challenges in addressing the mental health needs of persons with ID/DD. Responsibilities remain diffuse, resulting in fragmentation and deficiency in services (Freedom Commission, 2006; Fletcher, 1999
; Leismer, 1989). The prospect for establishing formal subspecialty training track in psychiatry of ID/DD in the United States, at best, is a work in progress. The residency training programs currently provide part-time rotations in ID/DD predominantly to help build capacity and confidence among trainees and to satisfy overall certification needs by the Accreditation Council for General Medical Education (ACGME). When exposed to persons with ID/DD, the trainees consistently value their clinical experiences as being formative, yet many are unable to pursue post-residency practices involving persons with ID/DD (Ruedrich et al, 2007
First, I discuss the historical development of two mutually exclusive ID/DD and mental health care systems in the United States beginning with the Kennedy era reforms. Second, I consider a number of historical and contemporary contributing factors that maintain the status quo for a lack of an organized training in psychiatry of ID/DD. Underlying historical legacy include lack of interest and training in ID/DD, view of ID/DD as being static, and influence of psychoanalysis in psychiatric training. Underlying contemporary factors include the lack of a developmental perspective in DSM-III, difficulty in integrating psychiatry within an interdisciplinary framework, difficulty in integrating psychiatry within a fragmented care system, and lack of incentives for training of psychiatrists in ID/DD. An organized subspecialty in psychiatry of ID/DD can help rectify this lack of convergence.