MENTALLY CHALLANED CHILD

INTRODUCTION:- The term ‘mental handicap’ is now used for the condition ‘ mental
retardation’ at least 2-3 % of Indian population are mentally handicap in any one form.

Mental retardation is the significantly sub-average general intellectual functioning

existing concurrently with deficits in adaptive behaviour manifested during the
developmental period. It includes low learning abilities poor maturation and social
maladjustment in combination.

The malfunctioning of the brain is poorly understood in most cases, but the
physiological alteration may be identified in some children. The cognitive and functional
ability are affected with limitation in adaptive ability and communication relationship self
direction health behaviour ,safety measure ,academic achievement ,leisure time utilization
and working capacity are altered in mentally handicapped children.

Mental handicaps are caused by multiple factors. In majority of the cases

(75%) causes are not precisely understood .The causative factor can be genetic, social and
physiological.

MENATAL HANDICAPS

Mentally handicapped children include,children with:

A. Mental retardation
B. Cerebral palsy

MEANTAL RETARDATION

The incidence of mental retardation is estimated to be about 2-3%

DEFINTION:-

mental retardation a disorder ,characterized by significantly sub

-average general intellectual functioning ,associated with significant improvement in
adoptive behaviour (including thinking, learning ,social and occupational adjustment) which
manifests during the development period (before 18 years of age ).

(According to Parul Dutta)

MEASUREMENT OF IQ

Intelligence quotient(IQ) = mental age × 100

Chronological age

CLASSIFICATION OF MENTAL RETARDATION

According of intelligence quotient ,mental retardation is of four types:

 1. MILD MENTAL RETARDATION
This is the commonest kind of mental retardation, accounting for 85-90% of cases .
children with IQ 51-70 fall in this category.
During infancy ,mild mental retardation often unnoticed. During late infancy and
early childhood the caregiver may note development delay in language ,social
development and ,motor skill ,during primary school ,these children may find problem
in reading and arithmetic with special education ,these children can progress up to 6th
grade in school. This group is referred to as’ educable’. In adulthood, mild mentally
retarded people may live independently

2. MODERATE MENTAL RETARDATION

About 10% of mentally retarded have moderate mental retardation .Their IQ is
between 36-50 moderate mentally retarded children display in motor development and
speech. Often they drop out of school after 2nd grade. They can be trained to support
themselves by performing semiskilled or unskilled work, under supervision, so this
group is referred to as ‘trainable’ during adulthood ,these people can work in
supervised occupational setting.

3. SEVERE MENTAL RETARDATION

About 4% of mentally retarded children fall in this category. Their IQ is between 21-
35 severe mental retardation is often recognized early in life, due to poor motor can
development and absent or markedly delayed speech and other communication skills.
Later in life, these children can be given elementary training in personal health care
and they can taught to talk. At the best, they can perform simple task under close
supervision .this group was earlier called ‘dependent’.

4. PROFOUND MENTAL RETARDATION

This group accounts for 1-2% of all mentally retarded. Their IQ is below 20. Physical
defects associated with mental retardation are seen in these children. The achievement
of development milestone is delayed. These children often need complete nursing care
of ‘life support’ under a carefully planned and structured environment like group
homes.

PROBLEM /DISORDERS ASSOCIATED WITH MENTAL RETARDATION

Disorder frequently found in mentally retarded children are:

a. Physical defects
1. Sensory disorder ( found in 20% cases)
 Defect in vision
 Defect in hearing
2. Motor defects
 Spasticity
 Ataxia( lack of coordination in doing voluntary activities)
  Epilepsy ( seen in several mentally retarded children
b. Psychiatric disorder
 Schizophrenia
 Neurosis
 Mood disorder
 Personality disorder
 Organic psychiatric disorder like dementia
 Autism and over activity syndrome
 Behaviour disorder like mannerism ,hand banging and hyperkinetic syndrome.

CAUSES OF MENTAL RETARDATION

a. Antenatal causes
 Deficiency of folic acid in mother
 Viral infection to mother during the first trimester of pregnancy ( such as
pertussis, mumps rubella, syphilis etc.)
 Exposure of pregnant ,female to radiations
 Consumption of drugs ,chemical for intoxicants by mother like lead
,thalidiomide etc.
 Placental dysfunction like hypothyroidism
 Endocrine disorder like hypothyroidism
b. Intra natal causes
 Birth asphyxia
 Prolonged or difficult labour
 Prematurity
 Instrumental delivery
 Birth injuries( head injury, intraventricular hemorrhage)
c. Post natal causes
 Cranial injuries ( accident and child abuse)
 Infection like meningitis and encephalitis
 Intoxication (lead)
 Kernicterus
d. Genetic cause
 Chromosomal anomalies like down syndrome, klinefelter’s syndrome fragile
x-syndrome ,trisomy x, turner’s syndrome.
e. Metabolic disorders
 Disorder of protein metabolism like phenylketonuria, maple syrup disease
,hartnup disease .
 Disorder of carbohydrate metabolism like galactosemia, gargoylism
 Disorder of purine metabolism like lesch-nyhan syndrome.
 Disorder of urea cycle like aminosuccinic aciduria, citruttinuria.
 Disorder of mucopolysaccharides like hurler’s syndrome.
  Miscellaneous disorder like wilson’s , toni- fanconi syndrome.

f. Disease of brain
 Tuberculosis sclerosis
 Epilepsy
 Neurofibromatosis
g. Cranial malfunction
 Microcephaly
 Anecephaly
 Hydrocephaly
h. Psychiatric disorder
 Autism
 Rett’s syndrome
 Childhood onset schizophrenia
 Aspergerf’s syndrome

DIAGNOSTIC EVALAUTION

The diagnostic of mental retardation is based on the following

1. Through physical examination and history

2. Routine development assessment
3. Standardized tests of intellectual and adoptive functioning. commonly used tests are
denver development screening test II, Stanford binet intelligence scale, Wechsler
intelligence scale, etc, A child whose found below 70 on Stanford binet test is
classified as ‘mentally retarded’

MANAGEMENT

There is no standard medical treatment of mental retardation ; however prevention is the best
approach. Prevention can be done at three levels:

1. Primary prevention
It consist of planned actions taken to reduce the incidence of mental retardation. It
involves strategies of health promotion and specific protection (identification of risk
factors and then removing them).
a. Health promotion
It includes:
i. Good antenatal care
ii. improving socioeconomic status of country
iii. education people
iv. family and genetics counselling
v. facilitating research to identify cause and risk factors of mental retardation
b. Specific protection
It includes:
 i. Good prenatal, intra natal and postnatal care.
ii. Genetic counselling of high –risk mother.
iii. Avoiding child birth in late maternal age.
iv. Avoiding consanguineous marriage.
v. Avoiding marriage of mentally retarded.
vi. Medical measure for preventing maternal infection during pregnancy(like
rubella, syphilis and toxoplasmosis), toxaemia of pregnancy ,trauma
,malnutrition ,obstetric complications, smoking alcoholism ,etc, which have
adverse effects on fetal development.
vii. Prematurity and neonatal medical condition (like kernicterus) should be
promptly managed.
2. Secondary prevention
It involves early diagnosis and care case finding, followed by intervention to limit the
disability.
a. Early detection and treatment
 It include early detection and treatment of preventable disorder which may
lead mental retardation like phenolketonuria (low phenylalanine diet must be
given to these patients), maple syrup urine disease ( lowbranched amino acid
diet is given to the child), hypothyroidism (thyroxin administration is
done),etc.
 Early detection and treatment of sensory, motor and behavioural handicaps.
 Early treatment of correctable disorders, e.g. infection (antibiotics are given),
skull configuration anomalies (surgical correction is done),etc.
 Early recognition of presence of mental retardation. A delay is diagnosis may
cause unfortunate delay in rehabilitation.
3. Tertiary prevention
Tertiary prevention aims to limit disability and promote rehabilitation.
a. Disability limitation
 Treatment of physical and psychological problem ( by drugs or
behavioural modification).
 Institutional care of severe or profound mentally retarded .
 Educational in special school, if educable.
 Vocational training ,if educable.
 Regular physiotherapy to treat associate defects.
b. Rehabilitation
 Rehabilitation in vocational ,physical and social areas is the corner stone
of management of mentally retarded children. It depend on patient’s
intelligence level and his capacities.

CARE OF HOSPITALIZED MENTALLY RETADRED CHILDREN

Mentally retarded children need hospitalization in the following condition

 a. Behavioural difficulties due to attention deficit hyperactivity disorder , destructive or
assaultive behaviour ,psychosis or organic psychosis.
b. Social factors like incompetent parents, single parents, overcrowded house, no one to
take care of child, etc.

COUNSELLING OF PARENTS

The parents of mentally retarded children require perseverance and patience, as they have to
make life long adjustments, counselling of parents helps them in taking proper care of the
child. It helps the parents and accept the child’s problem and plan his care accondingly.

Counselling should focus on:

i. Providing complete information about mental retardation.

ii. Developing right attitude of parents about their role in training of the child.
iii. Educating the parents about their role in training of the child.
iv. Providing information regarding professional help for treating associated condition or
complication like seizure, hyperactivity, psychosis etc.
v. Providing information regarding facilities available in the society for such
handicapped children like NGOs running day care centre’s shelter home ,special
school etc.

CEREBRAL PALSY

Definition palsy is chronic non- progressive motor dysfunction caused to due to the motor
areas of brain( Blosser and Burns, 2004)

The word’ cerebral’ refers to cerebrum which is the affected area of brain and ‘palsy’
refers to disorder of movement.

INCIDENCE AND ETIOLOGY

In 2007, the incidence of cerebral palsy was estimated to be 2.12- 2.45 per 1000 live
births.

Cerebral palsy is caused by damage to the motor control centers of the developing brain
which can occurs during pregnancy, childhood or after birth up to the age of three years.
This results in activity limitation, which is often accompanied by disturbance of
sensation, depth perception and other sight based problem, communication impairment
and cognitive, epilepsy is found in about one third of cases.

THE FACTOR CONTRIBUTING TO CEREBRAL PALSY ARE:

A. Prenatal factors
i. Genetics and chromosomal anomalies
ii. Brain malformation
iii. Exposure to teratogens
iv. Multiple futuses
 v. Intrauterine infection
vi. Placental problem causing insufficient nutrition and oxygen delivery to the
fetus
B. Birth factor
i. Preeclampsia
ii. Complicated labor and delivery
iii. Birth injury caused by direct head trauma
iv. Asphyxia secondary to card prolapsed or strangulation
C. Perinatal factor
i. Central nervous system infection
ii. Kernicterus
D. Childhood factors
i. Head trauma
ii. Meningitis
iii. Toxic ingestion like lead poisoning
iv. Shaken baby syndrome
v. Incidence causing hypoxia to brain like near drowning, choking due to foreign
body aspiration and poisoning.

CLASSIFICATION /TYPE OF CEREBRAL PALSY

Cerebral palsy is divided into four major classes according impairment and areas of brain thar
are damage. These four classes are:

1. Spastic cerebral palsy

This is the most common type of cerebral palsy occurring in 80% of all cases. These
patients have hypertonia and neuromuscular mobility impairment, due to upper motor
neuron lesion in the brain as well as corticospinal tract or motor cortex.
Spastic cerebral palsy is classification (on the basis of region of body affected ) into:

a. Spastic hemiplegia
In this type one side of the body is affected.

 Injury to the left side of the brain will cause right side deficit and vice
versa.
 These patient are most ambulatory of all forms of spastic cerebral palsy
 The affected persons have equines(limping instability) on the affected side
are prescribed ankle-foot orthosis to prevent equines.
b. Spastic diplegia
 In this type, lower extremities are affected with little or no upper body
spasticity.
 This is the most common form ,seen in 70-80% cases.
 These patients have a ‘scissors gait’.
  On the basis of gait analysis, patient are provided with walkers, crutches or
canes to help them in movement.
 These patients may also have nearsightedness or strabismus.
c. Spastic monopleghia
 One limb is affected
d. Spastic triplegia
 Three limbs are affected
2. Spastic quadriplegia
 Caused by damage to cerebellum.
 Occurs in about 10% of cases.
 Hypotonia and tremors may be present
 Wide based gait.
 Motors skill like writing, typing or using scissors might be affected.
3. Athetoid/ dyskinetics
 Athetoid cerebral cerebral palsy involves mixed muscle tone- both hypertonia and
hypotonia are present along with constant involuntary motion.
 Patient have trioble holding themselves in upright steady position for siting or
walking.
 Difficulty in holding object, especially small ones requiring fine motor control like
tooth brush or pencil.
 10% patients have this type of cerebral palsy.
4. Mixed type
 Symptoms of more than one form exist in these patients.

CLINICAL FEATURES

All types of cerebral palsy are characterized by the features:

 Abnormal muscle tone , reflexes or motor development and coordination.

 There can be joint and bone deformities and contractures(fixed, tight muscle
and joints).
 The classical symptoms are spasticity, spasm, other involuntary
movement(e.g. facial gestures), unsteady gait, problem with balance, and/ or
soft tissue finding consisting largely of decrease muscle mass.
 Scissor walking (where the knees come in and cross)and toe walking.
 Babies with severe cerebral palsy often have an irregular posture; their bodies
may be either very floppy or very stiff.
 Birth defects, such as spinal curvature, a small jawbone, or a small head
sometimes occur along with cerebral palsy.
 Speech and language disorder are common in people with cerebral palsy. The
incidence of dysarthia is estimated to range from 31 to 88%.
 Overall language delay is associated with problem of mental retardation ,
hearing impairment and learned helplessness.
  Pain is also associated with tight and/or shortended muscle, abnormal posture,
stiff joints, unsuitable othosis etc.

DIAGNOSTIC EVALUATION

The diagnostic of cerebral palsy has historically rested on the patients history and physical
examination. Once diagnosed with cerebral palsy, further diagnostic tests are optional. The
American academy of neurology suggested that neuroimaging with CT or MRI is also
capable of revealing treatable condition such as hydrocephalus , porencephaly, arteriovenous
nalformation and subdural hemotomas.

MANAGEMENT

Treatment for cerebral cerebral palsy is lifelong multi- dimensional process focused on the
maintenance of associated condition. Treatment may include one or more of the following:

1. Physical therapy
2. Occupational therapy
3. Speech therapy
4. Drug to control seizures pain , or relax muscle spasm(e.g. benzodiazepines, baclofen
and intrathecal phenol/baclofen), hyperbaric oxygen and the use of botox to relax
contracting muscles.
5. Surgery to correct anatomical abnormalities to release tight muscles.
6. Communication aids such as computers with attached voice synthesizers.

Treatment is usually symptomatic and focus on helping the person to develop as many
motor skills as possible.

1. Physical therapy
Physiotherapy program are designed to improve gait and voluntary movements,
together with stretching program to limit contractures. Life- long physiotherapy is
crucial to maintain muscle tone, bone structure, and prevent dislocation of the joint.

2. Occupational therapy
It helps adults and children maximize their functioning adopt to their limitation and
live as independently as possible. Occupational therapy enables individual with
cerebral palsy to participate in activities of daily living that are meaningful to them.
Occupational therapist work closely with families in order to address their concern
and priorities for their child. Occupational therapist may address issued related to
sensory ,cognitive or motor impairment resulting from cerebral palsy that affect the
child’s participation in self –care, productivity or leisure.

3. Speech therapy
It help control the muscle of the mouth and jaw, and helps improve communication .
speech therapy often start before a child begins school and continues throughout the
school year.
4. Biofeedback
It is an alternative therapy in which people with cerebral palsy learn to control their
affected muscle. Some people learn ways to reduce tension with this technique.

5. Massage therapy
It is designed to help relax tense muscle, strengthen muscle, and keep joint flexible.
6. Drug therapy
Botulinum toxin a injection are given in to muscle that are spastic or sometimes
dystonic, the aim being to reduce the muscle hypertonus that can be painful, a
reduction in muscle tone can also facilitate bracing and the use of othotics. Most often
lower exrimities muscle are injected and reinjection is needed every 4-6 months.
7. Surgery and orthosis
Surgery usually involves one or a combination of following:
 Loosening of tight muscle and releasing fixed joints, most often performed on
the hops , knees, hamstrings and ankles.
 Straightening abnormal twists of the legs bones, i.e. femur and tibia. This is a
secondary complication caused by the spastics muscle generating abnormal
forces on the bones.
 Cutting nerves of the limbs most affected by spasm. This procedure , called
rhizotomy(‘rhizo’ meaning root and ‘tomy’ meaning a cutting off) reduce
spasms and allows more flexibility and control of the affected limb and joints.
 Orthotic devices such as ankle-foot orthosis are often prescribed to minimize
gait. Irregularities and increase speed.

PROGNOSIS

Cerebral palsy is not a progressive disorder (means the brain damage does not
worsen), but the symptoms can become more severe more over severe over time
due to subdural damage. A person with the disorder may improve somewhat
during childhood if or she receive extensive care from specialties, but once bones
and muscularity become more established, orthopaedic surgery may be required.
SUMMARY :-

I Summarize my topic mental retardation a disorder ,characterized

by significantly sub -average general intellectual functioning ,associated with
significant improvement in adoptive behaviour (including thinking, learning
,social and occupational adjustment) and explain about the classification of mental
retardation , mild mental retardation, moderate and severe mental retardation and
enlist the cause of mental retardation antenatal causes , intra natal causes
,postnatal causes and describe the diagnostic evaluation of mentally retarded child.

CONCLUSION:-

I conclude my topic mental mental retardation a disorder

characterized by significantly sub -average general intellectual functioning
,associated with significant improvement in adoptive behaviour (including
thinking, learning ,social and occupational adjustment) and explain about
classification , causes , and diagnostic evaluation of mentally challenged child.
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C.M.NURSING INSTITUTE
NEHRU NAGAR, BHILAI
CHILD HEALTH NURSING
SEMINAR
ON
MENTALLY CHALLANGED CHILD

SUBMITTED TO: -
SUBMITTED BY: -
MR. P. K. MASIH
MS. JAMUNA KUMARI
ASSOCIATE PROFESSOR
M.Sc. NSG FINAL YEAR
CHILD HEALTH NURSING
CHILD HEALTH NURSING