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MENTAL RETARDATION

Meaning…
Mental retardation refers to substantial
limitations in present functioning and it
manifests before the age of 18.

It is characterized by significantly sub


average intellectual functioning,
existing concurrently with related
limitations in two or more of the
following applicable adaptive skill
areas:
Cont…..
communication
self-care
home living
social skills
community use
self-direction
health and safety
functional academics
leisure, and work
DEFINITION
 Mental retardation (MR) is defined
as significant intellectual or cognitive
limitations, and an inability to adapt
to the demands of everyday life.

(Sheerenberger (1983))
 Mental retardation (MR) refers to
significantly sub average general
intelligence that causes major
difficulties in activities of daily
living, and has manifested by age
18.
CLASSIFICATION
MILD MENTAL RETARDATION
Approximately 85% of the mentally
retarded population.
Their IQ score ranges from 50–70,
They can often acquire academic
skills up to about the sixth-grade level.
They can become fairly self-sufficient
and in some cases live independently,
with community and social support.
MODERATE MENTAL RETARDATION
 About 10% of the mentally retarded
population
 Their IQ scores ranging from 35–55.
 They can carry out work and self-care
tasks with moderate supervision.
 They typically acquire communication
skills in childhood and are able to live
and function successfully within the
community in such supervised
environments as group homes.
SEVERE MENTAL RETARDATION

 About 3–4% of the mentally retarded


population .
 Their IQ scores ranges from 20–40.
 They may master very basic self-care
skills and some communication skills.
 Many severely retarded individuals
are able to live in a group home.
PROFOUND MENTAL RETARDATION
 Only 1–2% of the mentally retarded
population
 Their IQ scores under 20–25.
 They may be able to develop basic
self-care and communication skills
with appropriate support and training.
 Their retardation is often caused by
an accompanying neurological
disorder.
 Profoundly retarded people need a
high level of structure and
AAMR CLASSIFICATION
(on the basis of support and
care )
 Intermittent
support
 Limited support
 Extensive support
 Pervasive support
DIAGNOSTIC CRITERIA

 MR is formally diagnosed by
professional assessment of
intelligence and adaptive behaviour.
DSM –IV diagnostic criteria
 a) An IQ below 70
 b) Significant limitations in two or
more areas of adaptive behaviour (as
measured by an adaptive behaviour
rating scale, i.e. communication, self-
help skills, interpersonal skills, and
more)
 c) Evidence that the limitations
became apparent before the age of
18
American Association of Mental
Retardation,
(classification on the basis of ICD
10 and DSM –IV)
Class IQ

 Profound mental retardation :Below


20
 Severe mental retardation :20–34
 Moderate mental retardation :35–49
 Mild mental retardation :50–69
 Borderline intellectual functioning :70–80
ICD 10
F70-F79
F70 Mild mental retardation
F71 Moderate mental retardation
F72 Severe mental retardation
F73 Profound mental retardation
F78 Other mental retardation
F79 Unspecified mental
retardation
ETIOLOGY
1.GENETIC FACTORS
 Down syndrome
◦ Trisomy 21
◦ Translocation of 21 and 15
 Fragile X syndrome
◦ mutation of X chromosome
 Prader Willi Syndrome
 Cast’s Cry(cri- du –chat) Syndrome
 Phenylketonuria
Cont…
 Rett’s disorder
 Neurofibromatosis( neuro-
cutaneous syndrome
characterised by ‘cafe au lait
spots’, optic gliomas and acoustic
neuromas)
 Adrenoleukodystrophy
 Maple syrup urine disorder
II. ACQUIRED AND
DEVELOPMENTAL FACTORS
prenatal period
 Maternal chronic illness
 Uncontrolled diabetes
 Anaemia
 Emphysema
 Hypertension
 Long term use of alcohol and narcotic
substance
 Viral infections
prenatal period Cont…
 Rubella (German measles)
 Cytomegalic inclusion disease
 Syphilis
 Toxoplasmosis
 Herpes simplex
 AIDS
 Foetal alcohol syndrome
 Prenatal drug exposure
 Complication of pregnancy
perinatal period

 Acquired childhood disorder


 Infections
 Iodine deficiency
 Head trauma
 Near Drowning
 Cardiac arrest ( during
anaesthesia )
perinatal period cont…
 Asphyxia
 Long term exposure of lead
 Exposure to mercury
 Intracranial tumours
 Surgery
 chemotherapy
III. ENVIRONMENTAL AND
SOCIOCULTURAL FACTORS

 Family instability
 Teenage pregnancies
 Mental disorder in parents
PSYCHOPATHOLOGY

MR is the manifestation of a group of


disorders of CNS function;
 Dysfunction is localized primarily to
the cortical structures, including the
hippocampus and the medial temporal
cortex.
CLINICAL FEATURES
Behavioural disturbances
 Aggression
 Self-injury
 Defiance (disambiguation)
 Inattention
 Hyperactivity
 Anxiety
 Depression
 Sleep disturbances
Behavioural disturbances cont…
 Stereotypic behaviours
 Difficult temperaments
 Noncompliance
 Hyperactivity
 Disordered sleep
 Colic
 Poor social skills
 Delays in play skills.
Language delay

•Delayed expressive language


•lack of expressive language
Fine motor/adaptive delay
 Significant delays in self-feeding,
toileting, and play skills
 Prolonged and messy finger feeding
often is accompanied by oral-motor
in coordination
 lack of interest in age-appropriate
toys
 imaginative play and reciprocal play
with age-matched peers
Gross motor delay

 Delays in gross motor development


infrequently accompany the
language and fine motor/adaptive
delays
 Subtle delays in gross motor
acquisition, or clumsiness
Neurologic and physical
abnormalities
 seizure disorders
Physical
Sensory examination
 Visual impairment (refractive errors,
strabismus, cataracts, abnormal
retinal pigmentation, and cortical
blindness)
 Hearing deficits
DIAGNOSTIC
MEASUREMENTS
 History and physical examination
 DNA analysis
 Karyotype at the 500 band level of
resolution
 Plasma amino acids
 Urinary organic acids
 Urinary muco-polysaccharides and
oligosaccharides
DIAGNOSTIC
MEASUREMENTS….

 Plasma 7-DHC (Smith-Lemli-


Opitz syndrome)
 Thyroid function tests
 Very-long-chain fatty acids
 Creatine kinase
Imaging Studies
 BrainMRI
 Head CT scan
 Skeletal films
Other Tests
PSYCHOLOGICAL ASSESSMENT
 Bayley Scales of Infant
Development
◦ Normalized for ages 2-30 months
◦ Subtest scores for receptive and
expressive language, nonverbal
problem-solving ability, and
sustained attention
 Stanford-Binet Intelligence Scale
◦ Normalized for ages 2 years to 23
years
◦ Fifteen subtests for assessment of
4 key areas of cognitive proficiency:
verbal reasoning, abstract/visual
reasoning, quantitative memory,
and short-term memory
 Wechsler Preschool and Primary
Scale of Intelligence-Revised
(WPPSI-R)
◦ Normalized for ages 3 years to 7.25
years
◦ Twelve subtests for assessment of
verbal and nonverbal intelligence
 Wechsler Intelligence Scale for
Children–IV (WISC-IV
◦ For ages 6 years to 16 years, 11
months
◦ Verbal and nonverbal intelligence
scores derived from 12 subtests
 Vineland Adaptive Behaviours
Scales
◦ For neonates to adults
◦ Measures ability to perform daily
activities required for personal and
social sufficiency; adaptive or
functional behaviours rated by
interviewing the child's guardian
 Deficiencies in at least 2 areas of
adaptive skills required to meet the
MR diagnostic criteria
ELECTROPHYSIOLOGICAL
STUDIES
 EEG, if clinically warranted
 Auditory evoked potentials in the
context of audiologic assessment
 Visual evoked potentials in cases
of profound delay and suspected
cortical blindness
MANAGEMENT
Primary prevention
Eliminate or reduce conditions that
lead to the disorders associated
with mental retardation.
 Family and genetic counselling
 Education to increase general public
knowledge
 Prenatal and postnatal medical care
 Supplementary enrichment
programs
Secondary and tertiary prevention

Education for the child


 It should include training in
adaptive skills , social skills,
vocation, communication and
quality of life.
Behavioural therapy
 To shape and enhance social
behaviours
 To control and minimize aggressive
and destructive behaviour
 Positive reinforcement for desired
behaviours
 Benign punishment( loss of
privileges
Cognitive Therapy
 dispelling false beliefs and relaxation
exercise with self instruction
Psychodynamic Therapy
 Used with patients and their family
members to decrease conflicts about
expectations that result in persistent
anxiety rage and depression
Family education
 The parents may benefit from the
continuous counselling or family
therapy should be allowed
opportunities to express their feelings
of guilt, despair, anguish, recurring
denial and anger about their child
disorder and their future
Social intervention
 Improving the quantity and quality of
social competence
 E.g.: special Olympic international
PHARMACOLOGICAL
Vitamin and mineral therapies
CNS stimulants
 psycho stimulants are prescribed
because of the coexistence of
attention deficit with or without
hyperactivity disorder in as many as
50%.
 The most widely used psycho
stimulants are methylphenidate and
Antidepressants
 These agents may be used when ADHD
is co morbid with depression.
 E.g. Bupropion
Alpha-adrenergic agonists
 These agents are used commonly to
modulate hyperactivity, aggression, tics,
and dyssomnias.
 E.g. Clonidine hydrochloride
 Guanfacine
Neuroleptic drugs (antipsychotics)
 The Neuroleptic drugs are the most
frequently prescribed agents for
aggression, self-injury, and
hyperactivity in people with MR.
Increasingly; they are more likely to
be reserved for the older child or
adult in whom intensive behavioural
intervention has failed.
 E.g. Risperidone, Haloperidol,
Aripiprazole
Nursing management
 Ineffective Health Maintenance
(Inability to identify, manage, and/or
seek help to maintain health)
 Chronic low self-esteem related to
ineffective or inadequate coping skills ,
feelings of helplessness.
 Risk for self-directed violence related
to depressed mood, hopelessness,
patient verbalizes suicidal thoughts
and feelings
Follow-up

 Individuals with MR should be


evaluated at least annually by a
neurologist or neurodevelopment
paediatrician with a special interest
in the etiology and management of
cognitive disorders.