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MENTAL RETARDATION

Introduction: Mental retardation (MR) or general learning disability is a

generalized disorder appearing before adulthood, characterized by significantly impaired cognitive functioning and deficits in two or more adaptive behaviors. It has historically been defined as an intelligence score under 70. Once focused almost entirely on cognition, the definition now includes both a component relating to mental functioning and one relating to individuals' functional skills in their environment. As a result, a person with a below-average intelligence quotient may not be considered mentally retarded. Syndromic mental retardation is intellectual deficits associated with other medical and behavioral signs and symptoms. Non-syndromic mental retardation refers to intellectual deficits that appear without other abnormalities.

Definition: The terms used for this condition are subject to a process called the euphemism treadmill. This means that whatever term is chosen for this condition, it eventually becomes perceived as an insult. The terms mental retardation and mentally retarded were invented in the middle of the 20th century to replace the previous set of terms, which were deemed to have become offensive. By the end of the 20th century, these terms them selves have come to be widely seen as disparaging and politically incorrect and in need of replacement. The term intellectual disability or intellectually challenged is now preferred by most advocates in most English-speaking countries.

The AAIDD have defined intellectual disability to mean the same thing as mental retardation. Currently, the term mental retardation is used by the World Health Organization in the ICD-10 codes, which has a section titled "Mental Retardation" (codes F70F79). In the future, the ICD-11 is expected to replace the term mental retardation with intellectual disability, and the DSM-

5 has replaced it with intellectual disability. Because of its specificity and lack of confusion with other conditions, mental retardation is still sometimes used in professional medical settings around the world, such as formal scientific research and health insurance paperwork.

Signs and symptoms The signs and symptoms of mental retardation are all behavioral. Most people with mental retardation do not look like they have any type of intellectual disability, especially if the disability is caused by environmental factors such as malnutrition or lead poisoning. The so-called "typical

appearance" ascribed to people with mental retardation is only present in a minority of cases, all of which involve syndromic mental retardation. Children with mental retardation may learn to sit up, to crawl, or to walk later than other children, or they may learn to talk later. Both adults and children with mental retardation may also exhibit some or all of the following characteristics: Delays in oral language development Deficits in memory skills Difficulty learning social rules Difficulty with problem solving skills Delays in the development of adaptive behaviors such as self-help or selfcare skills Lack of social inhibitors Children with mental retardation learn more slowly than a typical child. Children may take longer to learn language, develop social skills, and take care of their personal needs, such as dressing or eating. Learning will take them longer, require more repetition, and skills may need to be adapted to their

learning level. Nevertheless, virtually every child is able to learn, develop and become a participating member of the community. In early childhood, mild mental retardation (IQ 5069, a cognitive ability about half to two-thirds of standard) may not be obvious, and may not be identified until children begin school. Even when poor academic performance is recognized, it may take expert assessment to distinguish mild mental retardation from learning disability or emotional/behavioral disorders. People with mild MR are capable of learning reading and mathematics skills to approximately the level of a typical child aged 9 to 12. They can learn self-care and practical skills, such as cooking or using the local mass transit system. As individuals with mild mental retardation reach adulthood, many learn to live independently and maintain gainful employment. Moderate mental retardation (IQ 3549) is nearly always apparent within the first years of life. Speech delays are particularly common signs of moderate MR. People with moderate mental retardation need considerable supports in school, at home, and in the community in order to participate fully. While their academic potential is limited, they can learn simple health and safety skills and to participate in simple activities. As adults they may live with their parents, in a supportive group home, or even semi-independently with significant supportive services to help them, for example, manage their finances. As adults, they may work in a sheltered workshop. A person with severe or profound mental retardation will need more intensive support and supervision his or her entire life.[8] They may learn some activities of daily living. Some will require full-time care by an attendant.

Cause Among children, the cause is unknown for one-third to one-half of cases. Down syndrome, velocariofacial syndrome, and fetal alcohol syndrome are the

three most common inborn causes. However, doctors have found many other causes. The most common are: Genetic conditions. Sometimes disability is caused by

abnormal genes inherited from parents, errors when genes combine, or other reasons. The most prevalent genetic conditions include Down

syndrome, Klinefelter's syndrome, Fragile X syndrome (common among boys), Neurofibromatosis, congenital hypothyroidism, Williams syndrome, Phenylketonuria (PKU), and Prader-Willi syndrome. Other genetic

conditions include Phelan-McDermid syndrome (22q13del), Mowat-Wilson syndrome, genetic ciliopathy,[9]and Siderius type X-linked mental

retardation (OMIM 300263) as caused by mutations in the PHF8 gene (OMIM 300560). In the rarest of cases, abnormalities with the X or Y chromosome may also cause disability. 48, XXXX and 49,

XXXXX syndrome affect a small number of girls worldwide, while boys may be affected by 47, XYY, 49,XXXXY, or 49, XYYYY. Problems during pregnancy. Mental disability can result when the fetus does not develop properly. For example, there may be a problem with the way the fetus' cells divide as it grows. A woman who drinks alcohol (see fetal alcohol syndrome) or gets an infection like rubella during pregnancy may also have a baby with mental disability. Problems at birth. If a baby has problems during labor and birth, such as not getting enough oxygen, he or she may have developmental disability due to brain damage. Exposure to certain types of disease or toxins. Diseases like whooping cough, measles, or meningitis can cause mental disability if medical care is delayed or inadequate. Exposure to poisons like lead or mercury may also affect mental ability. Iodine deficiency, affecting approximately 2 billion people worldwide, is the leading preventable cause of mental disability in areas of the developing

world where

iodine

deficiency is endemic.

Iodine deficiency also

causes goiter, an enlargement of the thyroid gland. More common than fullfledged cretinism, as retardation caused by severe iodine deficiency is called, is mild impairment of intelligence. Certain areas of the world due to natural deficiency and governmental inaction are severely affected. India is the most outstanding, with 500 million suffering from deficiency, 54 million from goiter, and 2 million from cretinism. Among other nations affected by iodine deficiency, China andKazakhstan have instituted widespread

iodization programs, whereas, as of 2006, Russia had not. Malnutrition is a common cause of reduced intelligence in parts of the world affected by famine, such as Ethiopia. Absence of the arcuate fasciculus.

Diagnosis According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), three criteria must be met for a diagnosis of mental retardation: an IQbelow 70, significant limitations in two or more areas of adaptive behavior (as measured by an adaptive behavior rating scale, i.e. communication, self-help skills, interpersonal skills, and more), and evidence that the limitations became apparent before the age of 18. It is formally diagnosed by professional assessment of intelligence and adaptive behavior.

IQ below 70 The first English-language IQ test, the Terman-Binet, was adapted from an instrument used to measure potential to achieve developed by Binet in France. Terman translated the test and employed it as a means to measure intellectual capacity based on oral language, vocabulary, numerical reasoning, memory, motor speed and analysis skills. The mean score on the currently

available IQ tests is 100, with a standard deviation of 15 (WAIS/WISC-IV) or 16 (Stanford-Binet). Sub-average intelligence is generally considered to be present when an individual scores two standard deviations below the test mean. Factors other than cognitive ability (depression, anxiety, etc.) can contribute to low IQ scores; it is important for the evaluator to rule them out prior to concluding that measured IQ is "significantly below average". The following ranges, based on Standard Scores of intelligence tests, reflect the categories of the American Association of Mental Retardation, the Diagnostic and Statistical Manual of Mental Disorders-IV-TR, and the International Classification of Diseases-10

Class Profound mental retardation Severe mental retardation Moderate mental retardation Mild mental retardation Borderline intellectual functioning

IQ Below 20 2034 3549 5069 7084

Since the diagnosis is not based on IQ scores alone, but must also take into consideration a person's adaptive functioning, the diagnosis is not made rigidly. It encompasses intellectual scores, adaptive functioning scores from an adaptive behavior rating scale based on descriptions of known abilities provided by someone familiar with the person, and also the observations of the assessment examiner who is able to find out directly from the person what he or she can understand, communicate, and such like. This enables diagnosis to avoid the pitfall of the Flynn Effect which is a consequence of a periodic recalibration of average IQ (usually upwards) affecting the absolute values of the

standard deviation causing some people to fall into a different IQ range as-if overnight. Significant limitations in two or more areas of adaptive behavior Adaptive behavior, or adaptive functioning, refers to the skills needed to live independently (or at the minimally acceptable level for age). To assess adaptive behavior, professionals compare the functional abilities of a child to those of other children of similar age. To measure adaptive behavior, professionals use structured interviews, with which they systematically elicit information about persons' functioning in the community from people who know them well. There are many adaptive behavior scales, and accurate assessment of the quality of someone's adaptive behavior requires clinical judgment as well. Certain skills are important to adaptive behavior, such as: Daily living skills, such as getting dressed, using the bathroom, and feeding oneself Communication skills, such as understanding what is said and being able to answer Social skills with peers, family members, spouses, adults, and others

Evidence that the limitations became apparent in childhood This third condition is used to distinguish mental retardation from dementing conditions such as Alzheimer's disease or due to traumatic injuries with attendant brain damage.

Management By most definitions mental retardation is more accurately considered a disability rather than a disease. MR can be distinguished in many ways from mental illness, such as schizophrenia or depression. Currently, there is no "cure" for an established disability, though with appropriate support and teaching, most individuals can learn to do many things.

There are thousands of agencies around the world that provide assistance for people with developmental disabilities. They include state-run, for-profit, and non-profit, privately run agencies. Within one agency there could be departments that include fully staffed residential homes, day rehabilitation programs that approximate schools, workshops wherein people with disabilities can obtain jobs, programs that assist people with developmental disabilities in obtaining jobs in the community, programs that provide support for people with developmental disabilities who have their own apartments, programs that assist them with raising their children, and many more. There are also many agencies and programs for parents of children with developmental disabilities. Beyond that there are specific programs that people with developmental disabilities can take part in wherein they learn basic life skills. These "goals" may take a much longer amount of time for them to accomplish, but the ultimate goal is independence. This may be anything from independence in tooth brushing to an independent residence. People with developmental disabilities learn throughout their lives and can obtain many new skills even late in life with the help of their families, caregivers, clinicians and the people who coordinate the efforts of all of these people. Although there is no specific medication for mental retardation, many people with developmental disabilities have further medical complications and may be prescribed several medications. For example autistic children with developmental delay may be prescribed antipsychotics or mood stabilizers to help with their behavior. Use of psychotropic medications such

as benzodiazepines in people with mental retardation requires monitoring and vigilance as side effects occur commonly and are often misdiagnosed as behavioural and psychiatric problems.

Epidemiology Mental retardation affects about 23% of people.[8] 7590% of the affected people have mild retardation. Non-syndromic or idiopathic MR accounts for 3050% of cases.[8] About a quarter of cases are caused by a genetic disorder.

History of the terminology Several traditional terms denoting varying degrees of mental deficiency long predate psychiatry. All terms have been subjected to the euphemism treadmill. In common usage, these terms are simple forms of abuse. They are often encountered in old documents such as books, academic papers, and census forms (for example, the British census of 1901 has a column heading including the terms imbecile and feeble-minded). Negative connotations associated with these numerous terms for mental retardation reflect society's attitude about the condition. There are competing desires among elements of society, some of whom seek neutral medical terms, and others who want to use such terms as weapons with which to abuse people. Today, the term retarded is slowly being replaced by new words

like special or challenged. The term developmental delay is popular among caretakers and parents of individuals with mental retardation. Using the word delay is preferred over disability by many people, because delay suggests that a person is slowly reaching his or her full potential, rather than someone who has been disabled. Usage has changed over the years, and differed from country to country, which needs to be borne in mind when looking at older books and papers. For example, mental retardationin some contexts covers the whole field, but previously applied to what is now the mild MR group. Feeble-minded used to mean mild MR in the UK, and once applied in the US to the whole field. "Borderline mental retardation" is not currently defined, but the term may be

used to apply to people with IQs in the 70s. People with IQs of 70 to 85 used to be eligible for special consideration in the US public education system on grounds of mental retardation. Cretin is the oldest and comes from a dialectal French word for Christian. The implication was that people with significant intellectual or developmental disabilities were "still human" (or "still Christian") and deserved to be treated with basic human dignity. Individuals with the condition were considered to be incapable of sinning, thus "christ-like" in their disposition. This term is not used in scientific endeavors since the middle of the 20th century and is generally considered a term of abuse. Although cretin is no longer in use, the term cretinism is still used to refer to the mental and physical retardation resulting from untreated congenital hypothyroidism. Amentia has a long history, mostly associated with dementia. The difference between amentia and dementia was originally defined by time of onset. Amentia was the term used to denote an individual who developed deficits in mental functioning early in life, while dementia included individuals who develop mental deficiencies as adults. During the 1890s, amentia meant someone who was born with mental deficiencies. By 1912, ament was a classification lumping "idiots, imbeciles, and feeble minded" individuals in a category separate from a dement classification, in which the onset is later in life. Idiot indicated the greatest degree of intellectual disability, where the mental age is two years or less, and the person cannot guard himself or herself against common physical dangers. The term was gradually replaced by the term profound mental retardation. Imbecile indicated an intellectual disability less extreme than idiocy and not necessarily inherited. It is now usually subdivided into two categories, known as severe mental retardation and moderate mental retardation.

Moron was defined by the American Association for the Study of the Feeble-minded in 1910, following work by Henry H. Goddard, as the term for an adult with a mental agebetween eight and twelve; mild mental retardation is now the term for this condition. Alternative definitions of these terms based on IQ were also used. This group was known in UK law from 1911 to 1959/60 as feeble-minded. Mongolism was a medical term used to identify someone with Down syndrome. The Mongolian People's Republic requested that the medical community cease use of the term as a referent to mental retardation. Their request was granted in the 1960s, when the World Health Organization agreed that the term should cease being used within the medical community. In the field of special education, educable (or "educable mentally retarded") refers to MR students with IQs of approximately 5075 who can progress academically to a late elementary level. Trainable (or "trainable mentally retarded") refers to students whose IQs fall below 50 but who are still capable of learning personal hygiene and other living skills in a sheltered setting, such as a group home. In many areas, these terms have been replaced by use of "moderate" and "severe" mental retardation. While the names change, the meaning stays roughly the same in practice. Retarded comes from the Latin retardare, "to make slow, delay, keep back, or hinder," so mental retardation means the same as mentally delayed. The term was recorded in 1426 as a "fact or action of making slower in movement or time." The first record of retarded in relation to being mentally slow was in 1895. The term retarded was used to replace terms like idiot, moron, and imbecile because retarded was not (then) a derogatory term. By the 1960s, however, the term had taken on a partially derogatory meaning as well. The noun retard is particularly seen as pejorative; as of 2010, the Special Olympics, Best Buddies and over 100 other organizations

are striving to eliminate the use of the "r-word" (analogous to the "n-word") in everyday conversation. The term mental retardation is a diagnostic term denoting the group of disconnected categories of mental functioning such as idiot, imbecile, and moron derived from early IQ tests, which acquired pejorative connotations in popular discourse. The term mental retardation acquired pejorative and shameful connotations over the last few decades due to the use of the words retarded and retard as insults. This may have contributed to its replacement with euphemisms such as mentally challenged or intellectually disabled. Whiledevelopmental disability includes many other disorders (see below), developmental disability and developmental delay (for people under the age of 18), are generally considered more polite terms than mental retardation. United States In North America mental retardation is subsumed into the broader term developmental disability, which also includes epilepsy, autism, cerebral palsy and other disorders that develop during the developmental period (birth to age 18). Because service provision is tied to the designation developmental disability, it is used by many parents, direct support professionals, and physicians. In the United States, however, in school-based settings, the more specific term mental retardation is still typically used, and is one of 13 categories of disability under which children may be identified for special education services under Public Law 108-446. The phrase intellectual disability is increasingly being used as a synonym for people with significantly below-average cognitive ability. These terms are sometimes used as a means of separating general intellectual limitations from specific, limited deficits as well as indicating that it is not an emotional or psychological disability. Intellectual disability may also refer to the outcome of traumatic brain injury, lead poisoning, or dementing conditions

such as Alzheimer's disease. It is not specific to congenital disorders such as Down syndrome. The American Association on Mental Retardation continued to use the term mental retardation until 2006. In June 2006 its members voted to change the name of the organization to the "American Association on Intellectual and Developmental Disabilities," rejecting the options to become the AAID or AADD. Part of the rationale for the double name was that many members worked with people with pervasive developmental disorders, most of whom do not have mental retardation.

Distinction from other disabilities Clinically, mental retardation is a subtype of intellectual deficit, which is a broader concept and includes intellectual deficits that are too mild to properly qualify as mental retardation, or too specific (as in specific learning disability), or acquired later in life through acquired brain injuries or neurodegenerative diseases like dementia. Intellectual deficits may appear at any

age. Developmental disability is any disability that is due to problems with growth and development. This term encompasses many congenital medical conditions that have no mental or intellectual components, although it, too, is sometimes used as a euphemism for MR.