PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' October 2009 Vol. 60 No. 10 11229955 In Atkins v. Virginia the U.S. Supreme Court declared execu- tion of persons with mental retar- dation to constitute cruel and un- usual punishment, and thus to be unconstitutional under the Eighth Amendment. However, the Court left all considerations regarding how to implement the decision explicitly to the states. Since Atkins was decided in 2002, legis- latures, courts, and mental health experts have struggled with its implementation, highlighting the complexities that can arise when the courts base legal rules on clin- ical findings. This column reviews the Atkins case and considers the challenges associated with a clini- cal determination that can have life-or-death consequences for capital defendants. (Psychiatric Services 60:1295–1297, 2009) I n 2002 the U.S. Supreme Courtdeclared execution of persons with mental retardation to constitute cruel and unusual punishment, and thus to be unconstitutional under the Eighth Amendment (1). The case that trig- gered the decision, reversing an earli- er Supreme Court precedent (2), in- volved Daryl Atkins, a man with 16 prior felony convictions, who faced the death penalty for the abduction, robbery, and murder of an airman from a local military base. Since Atkins v. Virginia was decided, legis- latures, courts, and mental health ex- perts have struggled with its imple- mentation, highlighting the complex- ities that can arise when the courts base legal rules on clinical findings. Atkins represented a distinct break with the courts’ usual approach to the impact on sentencing of a defendant’s mental state at the time of the crime (3). At least since the U.S. Supreme Court decision in Lockett v. Ohio in 1978 (4), capital defendants have had the right to introduce evidence of their mental state at the sentencing hearing as a mitigating factor. In essence, defendants were permitted to argue that their mental retardation, mental illness, intoxication, or other impairing condition at the time of the crime so diminished their responsibil- ity for their actions that the ultimate penalty of death should not be im- posed. The jury was then charged with weighing evidence of the defen- dant’s mental state, along with other mitigating factors, against the nature of the crime and any other considera- tions that might be considered aggra- vating in deciding on a sentence. Precisely this process was followed in Daryl Atkins’ case. Testimony was presented on his behalf by an expert psychologist, who characterized him as having mild mental retardation, noting a full-scale IQ score of 59. A jury nonetheless determined that the death penalty should be imposed; af- ter the initial sentence was vacated because of a procedural error, a sec- ond jury—which listened to an addi- tional psychologist hired by the pros- ecution who testified that Atkins was of normal intelligence but had an an- tisocial personality disorder—again e ...

1. PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' October
2009 Vol. 60 No. 10 11229955
In Atkins v. Virginia the U.S.
Supreme Court declared execu-
tion of persons with mental retar-
dation to constitute cruel and un-
usual punishment, and thus to be
unconstitutional under the Eighth
Amendment. However, the Court
left all considerations regarding
how to implement the decision
explicitly to the states. Since
Atkins was decided in 2002, legis-
latures, courts, and mental health
experts have struggled with its
implementation, highlighting the
complexities that can arise when
the courts base legal rules on clin-
ical findings. This column reviews
the Atkins case and considers the
challenges associated with a clini-
cal determination that can have
life-or-death consequences for
capital defendants. (Psychiatric
Services 60:1295–1297, 2009)
I n 2002 the U.S. Supreme Courtdeclared execution of persons
with
mental retardation to constitute cruel
and unusual punishment, and thus to
be unconstitutional under the Eighth

2. Amendment (1). The case that trig-
gered the decision, reversing an earli-
er Supreme Court precedent (2), in-
volved Daryl Atkins, a man with 16
prior felony convictions, who faced
the death penalty for the abduction,
robbery, and murder of an airman
from a local military base. Since
Atkins v. Virginia was decided, legis-
latures, courts, and mental health ex-
perts have struggled with its imple-
mentation, highlighting the complex-
ities that can arise when the courts
base legal rules on clinical findings.
Atkins represented a distinct break
with the courts’ usual approach to the
impact on sentencing of a defendant’s
mental state at the time of the crime
(3). At least since the U.S. Supreme
Court decision in Lockett v. Ohio in
1978 (4), capital defendants have had
the right to introduce evidence of
their mental state at the sentencing
hearing as a mitigating factor. In
essence, defendants were permitted
to argue that their mental retardation,
mental illness, intoxication, or other
impairing condition at the time of the
crime so diminished their responsibil-
ity for their actions that the ultimate
penalty of death should not be im-
posed. The jury was then charged
with weighing evidence of the defen-
dant’s mental state, along with other

3. mitigating factors, against the nature
of the crime and any other considera-
tions that might be considered aggra-
vating in deciding on a sentence.
Precisely this process was followed
in Daryl Atkins’ case. Testimony was
presented on his behalf by an expert
psychologist, who characterized him
as having mild mental retardation,
noting a full-scale IQ score of 59. A
jury nonetheless determined that the
death penalty should be imposed; af-
ter the initial sentence was vacated
because of a procedural error, a sec-
ond jury—which listened to an addi-
tional psychologist hired by the pros-
ecution who testified that Atkins was
of normal intelligence but had an an-
tisocial personality disorder—again
endorsed the death penalty. Under
the rules then in place, having had the
opportunity to present his mental
state evidence to the jury for its con-
sideration, Atkins had received the
consideration to which he was enti-
tled. In challenging his sentence,
Atkins was asking the Supreme Court
to go beyond its traditional jurispru-
dence and recognize mental retarda-
tion as an absolute bar to imposition
of a death sentence.
Justice Stevens’ opinion for a six-jus-
tice majority did just that. Pointing to a

4. developing consensus among the
states that persons with mental retar-
dation had a reduced level of culpabil-
ity and should not be put to death, the
majority held that evolving standards
of decency precluded execution of
persons with mental retardation.
However, although Stevens recog-
nized that there might be serious dis-
agreement about whether a particular
defendant is mentally retarded, all
considerations regarding how to im-
plement the decision were explicitly
left to the states. Atkins’ own case was
remanded to the Virginia courts to de-
termine whether he was mentally re-
tarded and thus could not be executed.
Issues in applying Atkins
In the years since the decision in
Atkins, a considerable body of litera-
ture has developed, both legal and
clinical, considering the challenges
associated with a clinical determina-
tion that can have life-or-death conse-
quences for capital defendants.
Among the issues that have been ad-
dressed are the definition of mental
retardation, the means that should be
used to assess mental retardation, and
the procedures that should be fol-
lowed for the legal determination of
retardation, including the identity of
the decision maker. One wonders
whether, had the Court known just
how tangled these questions would

5. become, it might have decided Atkins
differently.
Defining mental retardation for
Mental Retardation and the
Death Penalty: After Atkins
PPaauull SS.. AAppppeellbbaauumm,, MM..DD..
Dr. Appelbaum, who is editor of this col-
umn, is the Elizabeth K. Dollard Professor
of Psychiatry, Medicine, and Law, De-
partment of Psychiatry, Columbia Uni-
versity. Send correspondence to him at
New York State Psychiatric Institute,
1051 Riverside Dr., Unit 122, New York,
NY 10032 (email: [email protected]).
LLaaww && PPssyycchhiiaattrryy
legal purposes offers a good example
of the complexities involved. In the
majority opinion, Atkins cited both
the American Association on Mental
Retardation (AAMR) and the DSM-
IV definitions of mental retardation,
which are similar but not identical.
Both DSM and AAMR approaches
embrace requirements for signifi-
cantly below-normal intellectual
functioning (usually evidenced by IQ
scores) combined with evidence of
deficits in adaptive functioning. The
2002 post-Atkins revision of the

6. AAMR definition reads, “Mental re-
tardation is a disability characterized
by significant limitations both in in-
tellectual functioning and in adap-
tive behavior as expressed in concep-
tual, social, and practical adaptive
skills. This disability originates be-
fore age 18” (5).
By leaving the definition of mental
retardation to each state to deter-
mine, however, Atkins led to the cur-
rent situation in which there are sig-
nificant differences across jurisdic-
tions, including major deviations
from both the DSM and AAMR ap-
proaches (6). Some states require
only “significantly subaverage intel-
lectual functioning,” while others de-
mand an IQ score below 70. Although
most states follow DSM and AAMR in
asking whether the impairments oc-
curred before age 18, at least three
states extend that to age 22, and one
speaks only of manifestations “during
the developmental period.” Kansas
uniquely mandates that the deficit in
intellectual functioning “substantially
impair one’s capacity to appreciate
the criminality of one’s conduct or to
conform one’s conduct to the require-
ments of the law.” With regard to
adaptive behavior, there are states
that speak of impairments only in
general terms, while others require
deficits in one or more specified do-

7. mains. The end result of this confus-
ing welter of definitions is that a de-
fendant might be considered mental-
ly retarded and ineligible for the
death penalty in one jurisdiction but
face execution in another.
Issues related to the definition of
mental retardation are likely to be-
come still more complicated over
time, as the concept of mental retar-
dation itself evolves. In 2007 the
AAMR changed its name to the
American Association on Intellectual
and Developmental Disabilities
(AAIDD), reflecting its desire to
avoid the stigma that had become at-
tached to the term mental retardation
(7). Experts in the field now argue
that intellectual disability, currently
the preferred term, should not be
viewed as an invariant personal trait
but as dependent on the interaction
between the person and a given envi-
ronment. Altering the environment
may reduce the level of disability,
perhaps below the point where the
person could be said to be disabled
(8). How this change may affect de-
fendants’ claims in capital cases re-
mains to be seen, but there is a risk
that the very concept on which the
Supreme Court relied to reach its de-
cision will mutate radically in coming
years.

8. Assessment of the intellectual and
adaptive deficits that all states require
for a determination of mental retar-
dation is another area of uncertainty.
With regard to intellectual perform-
ance, although an IQ below 70 has
been an informal landmark of mild
mental retardation, the AAMR defi-
nition avoids a fixed cutoff point and
the DSM refers to an IQ of “approxi-
mately 70” as the border. Where the
line should be drawn in a particular
case, however, is not a simple matter,
particularly when testing has been
performed on several occasions with
varying results, which often occurs.
Experts recommend that comparison
of an individual score to published
norms take into account errors in
measurement (3). Thus, an IQ of 71
can best be understood as expressing
a 95% likelihood that a person’s IQ is
between 65 and 77 (9). How certain
one wants to be that a defendant is
not mentally retarded before impos-
ing a death sentence will have an im-
pact on where the line is drawn, but a
95% level of certainty would appear
to require a minimum full-scale IQ
score of 78.
Another complicating variable is
the so-called “Flynn effect.” It is well
known that IQ scores tend to rise
over time, although the basis for this

9. phenomenon is unclear (10). In the
United States, IQ scores tend to rise
about .3 point per year. Hence, it has
been argued that raw scores should
be adjusted according to the number
of years since the test being used had
been normed. By using this ap-
proach, a defendant scoring 73 on a
test normed ten years previously
would have his score adjusted to 70,
on the basis that this score better re-
flects contemporary norms (10). In
addition, because many defendants
are tested more than once (usually at
least once by experts for the prose-
cution and again by experts for the
defense), some commentators be-
lieve that further adjustments should
be made for practice effects when
testing occurs at close intervals, per-
haps less than six months apart (3).
But how much to adjust any score is
unclear.
Assessing adaptive deficits leads to
still other conundrums. AAIDD rec-
ommends the combined use of stan-
dardized measures and structured in-
terviews, including information gath-
ered from people who have had a
chance to observe the person being
evaluated in various settings (5). Al-
though a plethora of standardized in-
struments exists to assess adaptive
functions, none have the broad ac-

10. ceptance of the major tests of IQ, and
the data they generate require an
even higher degree of interpretation
than IQ test scores (3,9). Moreover,
for defendants who have spent long
periods of time incarcerated, there
may simply not be enough evidence
of their ability to adapt in noninstitu-
tional settings to allow valid conclu-
sions to be drawn. Indeed, one com-
mentator has argued that none of the
existing tests assesses the kind of
adaptive deficits most prevalent
among persons with mild mental re-
tardation—gullibility and credulity—
though they are exactly the traits most
likely to result in their being drawn
into criminal activity (8).
Along with the uncertainties re-
garding the definition of mental re-
tardation and the assessment of core
deficits, the states have shown great
variability in the procedures estab-
lished for reviewing claims that a de-
fendant is mentally retarded (11).
Generally defendants must prove that
they are retarded by a preponderance
of the evidence, but some states re-
quire them to meet a more rigorous
PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' October
2009 Vol. 60 No. 1011229966

11. standard of clear and convincing evi-
dence. The determination is usually
made before the trial begins, so that
everyone can be aware of whether
the death penalty is at issue; howev-
er, in other states it will be raised be-
fore sentencing or as part of the sen-
tencing process. Judges will make the
decision in many states, but in some
jurisdictions the matter will be decid-
ed by a jury. Because there is reason
to believe that these procedural dif-
ferences may affect the outcome of
the legal determination regarding
whether the defendant is mentally re-
tarded, these variations can have im-
mense significance for persons facing
capital charges (11).
Atkins and its ironies
The difficulties in the application of
Atkins are no better exemplified than
by the proceedings involving Daryl
Atkins himself. After his case was re-
manded by the U.S. Supreme Court
to the Virginia courts, a third sentenc-
ing jury decided that he was not men-
tally retarded and again imposed a
death sentence. However, that sen-
tence too was overturned by the Vir-
ginia Supreme Court, on the grounds
that an unqualified psychologist had
offered testimony for the prosecution
and that the jury should not have
been told of Atkins’ previous sen-
tences (12). When the case was re-

12. turned for a fourth sentencing hear-
ing, something remarkable hap-
pened: the attorney for Atkins’ code-
fendant, who had fingered Atkins as
the triggerman—thus making him el-
igible for the death penalty—came
forward to say that his client had been
coached ten years earlier by the pros-
ecution to eliminate inconsistencies
in his account. On this basis, the trial
court vacated Atkins’ death penalty
and imposed a sentence of life in
prison, an action upheld by the Vir-
ginia Supreme Court in June 2009—
seven years after the U.S. Supreme
Court ruled on the case (13).
In the end, Daryl Atkins was spared
the death penalty, although he was
never able to convince a jury that he
was mentally retarded. However, the
rule spawned by his case lives on, and
indeed appeared to be influential in
the U.S. Supreme Court’s decision in
2005 to establish an absolute bar to
the death penalty for defendants un-
der the age of 18 at the time of their
crimes (14). The decision in Atkins
can be seen as a reflection of our so-
ciety’s deep ambivalence about the
death penalty; although reluctant to
surrender the option of imposing the
ultimate penalty, we are nonetheless
inclined to surround it with so many
restrictions that it will only rarely be

13. applied. Reliance on a clinical con-
cept for that purpose, though, has
produced a seemingly endless list of
challenges, illustrating once again
how poorly legal and clinical con-
structs mix.
References
1. Atkins v Virginia, 536 US 304 (2002)
2. Penry v Lynaugh, 492 US 302 (1989)
3. Bonnie RJ, Gustafson K: The challenge of
implementing Atkins v Virginia: how legisla-
tures and courts can promote accurate as-
sessments and adjudications of mental retar-
dation in death penalty cases. University of
Richmond Law Review 41:811–860, 2007
4. Lockett v Ohio, 438 US 586 (1978)
5. Mental Retardation: Definition, Classifica-
tion, and Systems of Supports. Washington,
DC, American Association on Mental Re-
tardation, 2002
6. Duvall JC, Morris RJ: Assessing mental re-
tardation in death penalty cases: crucial is-
sues for psychology and psychological prac-
tice. Professional Psychology: Research and
Practice 37:658–665, 2006
7. FAQ on Intellectual Disability. Washing-
ton, DC, American Association on Intellec-
tual and Developmental Disabilities. Avail-
able at www.aamr.org/content_104.cfm

14. 8. Weithorn L: Conceptual hurdles to the ap-
plication of Atkins v Virginia. Hastings Law
Journal 59:1203–1234, 2008
9. Everington C, Olley JG: Implications of
Atkins v Virginia: issues in defining and di-
agnosing mental retardation. Journal of
Forensic Psychology Practice 8:1–23, 2008
10. Flynn JR: Tethering the elephant: capital
cases, IQ, and the Flynn effect. Psychology,
Public Policy and Law 12:170–189, 2006
11. Reardon MC, O’Neil KM, Levett LM: De-
ciding mental retardation and mental ill-
ness in capital cases: the effects of proce-
dure, evidence and attitudes. Psychology,
Crime, and Law 13:537–557, 2007
12. Atkins v Virginia, 631 SE2d 93 (Va 2006)
13. In re Commonwealth of Virginia, 677 SE2d
236 (Va 2009)
14. Roper v Simmons, 543 US 551 (2005)
PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' October
2009 Vol. 60 No. 10 11229977
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/PTB
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22. 00e1006600690063006f002e002000500061007200610020006f0
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/DAN
<FEFF00420072007500670020006400690073007300650020006
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23. 0720020006f0076006500720068006f006c006400650072002000
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/NLD
<FEFF004700650062007200750069006b002000640065007a006
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24. 0020005000440046002f0058002d0033002e00200044006500200
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/ESP
<FEFF0055007300650020006500730074006100730020006f007
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25. 2006f006200610074002000790020005200650061006400650072
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/SUO
<FEFF004e00e4006900640065006e00200061007300650074007
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/ITA
<FEFF00550073006100720065002000710075006500730074006
500200069006d0070006f007300740061007a0069006f006e0069
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26. 07200650020006c006100200063006f006e0066006f0072006d00
69007400e0002000610020005000440046002f0058002d0033002
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/NOR
<FEFF004200720075006b0020006400690073007300650020006
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27. 6d007000610074006900620065006c002e0020005000440046002
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/SVE
<FEFF0041006e007600e4006e006400200065006e00640061007
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28. 6d006100740069006f006e0020006f006d0020006800750072002
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002d0064006f006b0075006d0065006e007400200073006f006d0
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07200200034002e003000200065006c006c006500720020007300
65006e006100720065002e>
/ENU (DSC Distiller 7 Basic - Non Ad Managment)
>>
>> setdistillerparams
<<
/HWResolution [2400 2400]
/PageSize [612.000 792.000]
>> setpagedevice