Psychiatry Mental retardation and learning disorders Dr.

Yu 3rd shifting/October 22, 08 Juday and forever friends MENTAL RETARDATION Philippine Stats: DepEd Children with special needs are enrolled in schools Mentally gifted/fast learners (G/FL) Are children with disabilities Mentally retarded Weschler Test IQ scores fairly stable Individually administered tests WISC IV (age 6-16 yrs) WAIS III (age 16-89 yrs) WPPSI-R (age 2.5-7 yrs) Adaptive Functioning Tests a. Vineland Adaptive Behavior Scale 4yrs and 11mos old semi-structured interview involving parents, teachers, and caregivers communications, daily living skills, socialization and motor skills b. Woodcock-Johnson Scale of Independent Behavior c. American Association on Mental Retardation Adaptive Behavior Scale Traditionally, mental retardation is known as a. Cretin oldest term, coined from a French word people with significant intellectual or developmental disabilities were “still human” and and deserved to be treated with basic human dignity b. Idiot from Greek Word idiotos, meaning unfit for public life c. Imbecile indicated an intellectual disability less extreme than idiocy and not neccesaarily inherited. d. Moron defined by the American Association for the Study of the Feeble-minded in 1910 adult with a mental age between 8 and 12 Degrees of severity Moron - Mild Imbecile - Moderate - Severe Idiot - Profound Mild Mental Retardation IQ range from 50-55 to 70 85% of mentally retarded people identified in Grade 1 or 2 specific causes unidentified Prognosis: can be independent with appropriate support teachable Moderate Mental Retardation IQ range: 35-40 to 50-55 10% of MR Early childhood: adequate language skills School age: poor academic achievement Teens: poor socialization Adult: semiskilled work with supervision trainable Severe Mental Retardation IQ range from 20-25 to 35-40 4% of MR can count and recognize words that are needed for functioning cause: usually identifiable

156,270 77,152 79,118 12,456

What is IQ? Developed by French psychologist Alfred Binet in 1904 “quotient” refers to Binet’s definition of IQ ___mental age___ x100 chronological age Modern IQ tests deviation IQ refernced to other people Mental Retardation Not a disease Result of a pathological process in the brain Limitations in intellectual and adaptive function Alternative terms: Developmental delay imply that appropriate intervention will improve or completely eliminate the condition “catching up” a term for a pattern of persistently slow learning of basic motor and language skills (milestones) during childhood, and a significantly below-normal intellectual capacity as an adult. Mental impairment - state of arrested or incomplete development of mind which includes: significant/severe impairment of intelligence and social functioning and is associated with abnormally aggressive or seriously irresponsible conduct on the part of the person concerned. (mental health act 1983) a disability characterized by significant limitations both in intellectual functioning and in adaptive behavior as expressed in conceptual, social and practical adaptive skills. This disability originates before the age of 18. (American Association on Mental Retardation, 2002) DSM-IV TR definition IQ (as measured by standard tests) is subaverage (<70 or <2SD from mean) and a measure of adaptive function in at least 2 areas is deficient Communication Self-care Home living Social/interpersonal Self-direction Works Leisure Health and safety Funcational academic skill Use of community resources Intelligence Tests Stanford-Binet Intelligence Scale comprises 15 subsets assess 4 areas of intelligence: verbal abilities, abstract/visual thinking, quatitative reasoning, shortterm memory

adults: supervised living situations (home) Profound Mental Retardation IQ below 20 or 25 1-2% of MR cause: identifiable children: self-care skills and may learn to communicate needs with training Epidemiology US: 1% of the population Highest incidence: school-aged (10-14y/o) 1.5x more common in men than women if sever or profound: higher mortality due to complications of associated physical disorders Co-morbidity 2/3 of children and adults have comorbid mental disorders correlates with severity of MR mood disorders, schizophrenia, autistic disorder and pervasive dev d/o neurologic disorders (seizures) genetic syndromes Fragile X, Prader-Willi and Down Syndrome Etiology genetic acquired environmental/social Genetic causes of MR abnormalities in autuosomal or sex chromosomes from advanced maternal or paternal age X-ray radiation Down syndrome Fragile-X syndrome Prader-Willi syndrome Cri-du-Chat syndrome MSUD (Maple syrup urine dse) Acquired and environmental factors maternal chronic illness (diabetes, hypertension) infection (TORCHSS, AIDS) narcotic and alcoholic substance (ab)use perinatal period (prematurity, LBW, ICH) aquired childhood disorders (encephalitis, meningitis, head trauma) Environmental/Social Factors deprivation of nutrition and nurturance family instability children of psychotic patients Differential Diagnosis learning disorders pervasive developmental disorders Treatment Primary prevention – gentic counseling and good prenatal care Secondary prevention – treat the comorbid condition Tertiary prevention behavioral, cognitive, psychodynamic therapies Education for child and family Pharmacology for co-morbidities Course and prognosis usually the underlying intellectual impairment does not improve adaptive skills can be enriched by a supportive environment limited by existing co-morbidities

LEARNING DISORDERS Case Study Sarah hates reading aloud in class. She’s never been a good reader, and even when she recognizes the words on the page, she seems to have trouble reading them correctly. School’s never been her favorite place anyways because her teachers always complain of her writing and her spelling. She often gets discouraged, thinking that she’s not as smart as other students. Fortunately, Sarah has discovered she has talents that other don’t. She’s great at dreaming up costume and scenery ideas in drama club, and she’s one of the best artists in her school. Sometimes, she wonders how she can do so well in some areas of her life and so poorly in others. What Sarah, her parents, and her teachers don’t realize is that Sarah has a learning disorder. Learning Disorder neurologic in origin, and it impedes a person;s ability to store, process and/or produce information clinical feature of a learning disorder is the lack of normal developmental skill expected in a child, either cognitive or linguistic measured by individually administered standardized tests substantially below that expected of a person’s chronological age, measured intelligence and ageappropriate education significantly interferes with academic achievement or activities of daily living requiring the specific ability (reading, writing, matematics) the difficulty is in excess of those usually associated with a sensory deficit (if present) Evaluation History – ask for past medical, family, maternal, and developmental history Do complete physical examination, neurologic and developmental assessment Take note of any associated medical condition, and treat as necessary (eg ADHD) Refer to specialists once diagnosis is made Work up patients as needed Hearing tests Eye examination Reading Disorder aka dyslexia word blindness reading backwards learning disability impaired ability to recognize words slow and inaccurate reading poor comprehension Epidemiology 1 out of 20 school children half of those receiving special education boys>girls increased risk of comorbidity ADHD 25% cases Disruptive behavior disorders Depressive disorders Clinical Features identified by age 7 usually bright kids who excel in non-reading activities (arts, drama, music, sports) “bibo kids” falling behind in subjects that require reading dislikes and avoids reading and writing relies heavily on memorization

patient complains of seeing words upside down, or dancing on the page makes errors in oral reading omissions/additions distortion of words reads slowly with minimal _____ associated language difficulties impaired sound discrimination difficulty sequencing words “zones out” during study session tends to be angry and depressed and exhibit low selfesteem Treatment do not aggravate situation tell teachers not to call the patient in front of the class to read advise an after-school reading program or a reading tutor use of recorders to take note of assignments giving exams verbally Writing Disorders aka dysgraphia spelling dyslexia spelling disorder writing is a complex task that requires integration of cognition, language and motor skills children experience this disorder as “thoughts that move faster than their hands can translate them onto papers” Epidemiology 4% of school-aged children boys>girls comorbidity reading disorder ADHD, oppositional ??? disorder Language disorder Depression and poor self-esteem Etiology - anatomic injury to or vascular abnormalities in the posterior corpus callosum or superior temporal gyrus - other medical condition epilepsy Clinical Features Diagnosis made during the second (script na kasi magsulat) letter reversal letter inversion transpositions word reversal number reversal year of elementary grade (b-d) (p-q) (m-w) (felt-left) (was-saw) (14-41)

Epidemiology 6.4% of school-aged children girls>boys may occur in isolation or in conjunction with 56% of children with RD disorders of written expressions expressive language disorder developmental coordination disorder Etiology multifactorial arithmetic skills depend more on the amount and quality of instruction Clinical Features detected duing the 2nd and 3rd grade poor achievement in the following skills perceptual mathematical linguistic – word problems into numbers attentional – ADHD Treatment children with MD usually perceive the subject as threatening and intimidating in school, advixe teachers regarding the student they must not be asked to answer questions in class do not allow other students to correct papers of those with MD giving them more time to solve problems or allowing them to solve fewer problems at home, parents should be advised to be nonjudgmental and make mathematics fun whenever possible supervised/tutorial practice in solving mathematical problems teach mathematics through real-life situation allowing the use of calculators or other tools to solve problems for the child explain that mathematics is only 1 of the many forms of intelligence and reassure them that they are competent individuals encourage them to have a degree of optimism towards the subject, let them perceive this as a challenge to conquer HOW TO KNOW IF A CHILD HAS A LEARNING DISORDER Ages 3 to 5 does your preschooler… seem uninterested in playing games with language sounds, such as repetition and rhyming? Have trouble learning nursery rhymes, such as “Humpty Dumpty” or “Jack and Jill”? Frequently mispronounce words and persist in using baby talk? Fail to recognize the letters in his or her name? Have difficulty remembering the names of letters, numbers or days of the week? Ages 5 to 6 does your kindergartner… fail to recognize and write letters, write his or her name or use invented spelling for words? Have trouble breaking spoken words into syllables, such as cowboy into cow and boy? Still have trouble recognizing words that rhyme, such as cat and bat? Fail to connect letters and sounds? (ask your child: what does the letter b sound like?)

Treatment use of computers with spell check and grammar check use of programs that translate voice to typewritten words assistance with note taking (buddy system, prepared notes) give ample time to finish writing essays allow to use scribes if output is needed using other methods to grade student (eg. Recitation) Mathematics Disorder aka dyscalculia congenital arithmetic disorder Gerstmann syndrome Have difficulty remembering numbers Slow, inaccurate in computation

Fail to recognize phonemes? (ask your child: what starts with the same saound as cat--dog, ma or car?) Ages 6 to 7 does your first-grader… still have difficulty recognizing and manipulating phonemes? Fail to read common one-syllable words, such as mat or top? Make reading errors that suggest a failure to connect sounds and letters, such as big for goat? Fail to recognize common, irregularly spelled words, such as said, where and two? Complain about how hard reading is and refuse to do it? Age 7 and older does your child mispronounce long or complicated words saying “amulium” instead of “aluminum”? confuse words that sound alike, such as tornado for volcano, or lotion for ocean? Speak haltingly and overuse vague word such as stuff or things? Have trouble memorizing dates, names, and telephone numbers? Have trouble reading small function words, such as that, an and in? Guess wildly when reading multisyllabic words instead of sound them out? Skip parts of words, reading conible instead of convertible, for example? When reading aloud often substitute easy words for hard ones, such as car for automobile? Spell terribly and have messy handwriting? Have trouble completing out homework or finishing tests on time? Have a deep fear of reading aloud?