MENTAL RETARDATION[MR]

Also is known as COGNITIVE DEVELOPMENTAL DELAY Mental retardation refers to the most severe general lack of cognitive and problem solving skills. Mental retardation is the significant sub average general intellectual functioning existing concurrently with deficits in adaptive behaviours and manifested during the developmental periods. Presentation of a child with mental retardation Low learning capacity Poor maturation & Inadequate social adjustment

INCIDENCE In general population 2-3 % children are mentally retarded. About th of total cases are only mild type and 5 % care having severe to profound mental retardation. MENTAL RETARDATION Mental retardation is calculated depending upon IQ level.IQ or intelligence Quotient is calculated by the formulaIQ = Assessed mental age Chronolofgical age CLASSIFICATION The mental retardation can be classified asMild mental retardation Moderate mental retardation Severe mental retardation Profound mental retardation [IQ LEVELS] 51 to 70 36 to 50 21 to 35 <20 x 100

*IQ LEVEL between 71 to 90 borderline intelligence: who are vulnerable to learning problems and usually sorted out. They need special help in regular classes in school. They are not included in mentally handicaps. *MILD MENTALLY RETARDED CHILDREN need some special class placement and can attain only upto 4th to 6th standards at school levels. They are designated as educable

*MODERATELY MENTALLY RETARDED children can be able to attain upto 2nd class standards in academic skills. They are considered as trainable. They can learn maximum upto self care activities. *SEVERELY MENTALLY RETARDED children can learn only self care and simple conversational skills. They need much supervision and considered as custodial Some degree of education and training are possible for all groups of mentally retarded children, even in severe and profound mental handicaps. ETIOLOGY OF MENTAL RETARDATION The etiology of mental retardation are multifactorial and may be combination of medical, socio cultural and psychological factors. Approximately in 50% of MR children no identifiable organic or medical cause can be found. The pre disposing factors of the condition include poor socio economic status, low birth weight, advanced maternal age and Consanguineous marriage.

The potential contributory factor or the possible identifiable causes of mental retardation can be as follows Genetic syndromes- e.g. downs syndrome, fragile X-syndrome, galactosemia, klinefelters syndrome etc. Congenital anomalies-e.g. congenital hydrocephalus, micro cephaly, cranial malformations, craniosynstosis. Intra uterine influences-e.g. maternal infections, exposure to teratoigens, placental insufficiency, pre eclampsia, ante partum haemorrhages etc. Perinatal conditions-e.g. birth trauma, perinatal asphyxia, intra cranial hemorrhage, prematurity, low birth weight etc Post natal conditionse.g. CNS infections, kernicterus, head injury, toxic or post vaccination encephalopathy, thrombosis of cerebral vessels, iodine deficiency, hypothyroidism, severe PEM, metabolic disorders-PKU, galactosemia etc Environmental and socio cultural factors-e.g. poverty, broken family, faulty parenting, child abuse and neglect, parental psychopathology and environmental deprivation.

CLINICAL MANIFESTATIONS The child with MR presents with failure to achieve age appropriate development to some degree. The mental age is below the chronological age. There is poor maturation with learning difficulties and inappropriate family and social adjustment.

IN INFANCY Poor feeding Weak or un co ordinate sucking leading to poor weight gain, delayed or decreased virtual alertness and auditory response Reduced spontaneous activity Delayed head and trunk control Hypotonia and spastic muscle tone Poor mother child interaction.

IN TODDLER Delayed speech and language disabilities Delayed motor mile stones (standing, walking) Failure to achieve independence (like self feeding, dressing and toilet training) Short attention span and distractibility Clumsiness Hyperactivity Poor memory Poor concentration Emotional instability Sleep problems Impulsiveness and Low frustration tolerance.

Convulsions are commonly found with MR . associated defects of musculoskeletal system, vision and hearing are commonly present. Congenital anomalies are often associated. Neuro de generative disorders, psychiatric illness, emotional problems and cerebral palsy may be found along with mental retardation`. The presence of physical characteristics like micro cephaly, downs syndrome, cretinism, mucopolysacharidosis. DIAGNOSIS Clinical manifestations and physical characteristics Physical and neurological examination History: Detailed history of developmental period ; Family history and history of past illnesses. IQ TESTS KARYO TYPING: Detection of associated diseases or etilogical factors like downs Investigations: Urine test for metabolic diseases, urine chromatography, chromosomal studies, hormonal assay, enzyme estimation, serological best to detect intra uterine infections CSF study

X-ray skull EEG CT scan MRI Angiography etc.

In suspected cases pre natal diagnosis can be done by amniocentesis. MANAGEMENT Principles of management Relieve the anxiety and stress of the child and the family Seek a way to circumvent the handicap Encourage development esp. in areas least affected by the handicaps Therapeutic programme to help to reduce handicaps

Action plan is formulated on the following Assessing the childs capabilities Early stimulation and education Behavioural modification techniques School placement or home education Employment, medical problems etc

Genetic counselling For inherited disorders Antenatal diagnosis

Supportive treatment Managing associated handicaps

NURSING DIAGNOSES Impaired verbal communication Altered family process Altered growth and development Altered health maintenance High risk for infectiuon Altered role performance Self care deficit High risk for impaired skin integrity Impaired social interaction Social isolation

NURSING INTERVENTIONS Needs management in multi disciplinary team approach

Adequate diagnostic facilities to detect associated problems and appropriate management of the specific conditions should be arranged Provide counselling or refer to appropriate counselling services for family members and parents regarding various aspects of the condition and necessary management. Provide psychological and emotional support needed for parents and family members. Educate the parents and family members on the childs need for love, affection, appreciation, discipline and minimal criticism for tender loving care Parents should be explained, informed and discussed about the long term care at home situation according to the childs IQ level and associated problems. Promote self care ability and independence of the child. Provide routine basic care, immunisation, growth monitoring, nutritional requirements and tender loving care to the child. Discuss about the necessary drug therapy i.e. prescribed to the parents. Discuss about the special educational arrangement and available facilities with the parents Educate the parents and family member that the child needs support to develop potentials to the maximum and to become independent as possible for self help.

PREVENTTION General/ socio economic improvement Nutritional improvement of pregnant mothers Prevention of hazardous drugs, radiation etc in pregnancy Good obstetric care Treatment of hyperbilirubinemia Prevent consanguineous marriages MTP in antenatally proven disorders.