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Introduction Mental retardation/intellectual disability is a condition of arrested or incomplete development of mind. It is characterised by delayed development of skills, eg. language, thinking and movement and social skills. Adaptive behaviour is impaired, and the risk of exploitation is increased. Educational progress is limited. Mentally retarded children have an increased rate of other psychiatric disorders, and in particular, may show significant behavioural problems. The onset of mental retardation is before the age of 18 years. Causes Various factors cause mental retardation in the period before birth, during birth and after delivery. Let us look at the factors in each stage. a. Before birth: · Infections like German measles (Rubella), cytomegalovirus infection, toxoplasmosis, HIV infection, herpes simplex infection and syphilis; · Poor nutrition during pregnancy; · Toxins: alcohol, herbs, cocaine, lead, maternal tobacco smoking; · Hereditary causes: one or both parents may be of low intelligence; · Placental insufficiency; · Chromosomal disorders; · Congenital malformations of the central nervous system. b. During delivery: · Extreme prematurity; · Hypoxic-ischaemic injury; · Intracranial bleeding during difficult or forceps delivery; · Low blood sugar; · Increased blood bilirubin levels; · Infections (herpes simplex, bacterial meningitis). c. After delivery: · Infections (encephalitis, meningitis); · Severe head injury; · Lack of oxygen;
· Low blood sugar levels. · Poverty and family disorganization. If you see a child who is very late in achieving his or her milestone. · Malnutrition. · Toxins (lead). If a child is emotionally and/or intellectually deprived or neglected. his intelligence may suffer permanent damage. · Parental drug abuse. you should suspect mental retardation. · High blood sodium levels. Clinical manifestations The delayed achievement of developmental milestones is the main symptom. · Parental psychopathology. · Dysfunctional infant-caretaker interaction. FIGUREYou can also identify a child with mental retardation by comparing him with children of a similar age or by going through the following development milestones . A child’s brain needs stimulation to function properly. · Intracranial bleeding.
solve problems. There is an increased incidence of epilepsy in such children. b. some will not achieve the ability to care for themselves. a 10. and enjoy simple social activities. Mental age is the age level at which the child is functioning. Severe Retardation (IQ 25 – 40): . Mild retardation (IQ 55 – 70): Most children with mild mental retardation acquire adequate speech for conversation and are able to care for themselves eventually. Unless associated with autism or other psychiatric problems. These are: · the ability of a child’s brain to learn. and make sense of the world (intelligence quotient or IQ). such children would be able to communicate with others. Moderate Retardation (IQ 40 – 55): Children with moderate mental retardation are slower in developing. Some special educational input is likely to be needed. a. The normal intelligence quotient is 75 to 120. but their development will be delayed. c. and · whether the child has the skills he or she needs to live independently (called adaptive behaviour. Such children will require ordinary care which may need to continue for slightly longer than with normal children. think. most learn to care for themselves with supervision. For example. though the nature of the care would be much as for a normal younger child. or adaptive functioning). Intelligence Quotient (IQ) The diagnosis of mental retardation requires finding of sub-average intellectual functioning. Mentally retarded children can be classified under four main categories. Care would be required for significantly longer than normal children. A child who has an intelligence quotient of 70 or below is said to have a significantly sub-average intellectual functioning. That child’s is intelligence quotient is 5 ÷ 10 x 100 = 50.year-old who copes with normal activities at the level of a 5-year-old has a mental age of five. Such a child has mental retardation. Intelligence quotient is the ratio between child’s mental age and his/her chronological age multiplied by 100.Diagnosis The diagnosis of mental retardation is made by looking at two main things.
Two thirds have epilepsy: associated cerebral palsy and sensory impairment are common. they may be immobile.Children with severe mental retardation have more limited development. Often mental retardation is caused by conditions called syndromes. flattened nose. The individual with Down syndrome will have an extra chromosome on the 21st chromosome and is sometimes called Trisomy 21.they are at increased risk of heart disease and gum disease. One third have epilepsy. and walking. Potential feeding problems can include: · Tongue control. tongue thrust · Endurance during feeding because of cardiac problems (primarily for infants) · Oral-motor problems Oral problems can include oral hypotonia. The normal genetic pattern of chromosomes is when each individual has 23 pairs in each cell or a total of 46 chromosomes. Their growth may be slower. and they are often shorter than other classmates. with no prospect of eventually caring for themselves. low set ears. The infant may be born with a heart defect. or incontinent. and it is common for the infant to have slanted eyes. They have no ability to care for their own basic needs. Nutrition problems are individualized. and delayed and/or abnormal tooth eruption. There are often associated neurological problems affecting mobility. is the potential to be overweight. and require constant help and supervision. Profound Retardation (IQ 20 – 25): Such children are severely limited in their communications. Down Syndrome is a disorder of the chromosomes. d. problems with tongue protrusion. Many infants with Down syndrome develop slowly related to cognitive and motor skills. These children often have feeding problems due to a weak “suck” and are slow to cut their teeth. crawling. Two of the most common are Down syndrome and Prader-Willi syndrome. and low muscle tone. The incidence of Trisomy 21 or Down syndrome is 1 in 600 live births. Poor sucking in infancy difficulty in transition to textured food What to expect in the Diet Prescription . small oral cavity causing tongue protrusion. but their most frequent problem when school age. Syndromes are defined as a set of characteristics which occur together.
They have risk of Diabetes Mellitus and PICA (a craving for unusual or inedible items. Texture modification for chewing and swallowing problems 3. However. Therefore. their appetite remains the same and supervision is required to control the food consumed. the PW child’s health picture is greatly improved. Potential feeding problems can include: · Hypotonia as an infant · Weak suck as an infant Hyperphagia in childhood and adolescence What to Expect in a Diet Prescription 1. difficulty in sucking and swallowing. this can be lifethreatening. The PW infant has very low muscle tone. it is now identified shortly after birth and appears with characteristics similar to Down syndrome. increased activity. and they may require a calorie restricted plan. Although PW is less frequent than Down syndrome. which can be difficult due to the low muscle tone.1.) . limiting their intake and the availability of food is extremely important. Supervision to prevent food seeking (Environmental controls are essential because children with PW cannot control this continual urge to obtain additional food. and use of growth hormone. and may have failure to thrive. Under current treatment with controlled food intake. Later in the preschool period. Individuals with PW require regular physical activity. Low calories for the child who is overweight 2. Decreased calories 2. most children with PW have an overwhelming appetite and lack the ability to know when they are full and these individuals become extremely obese. Self-feeding devices Prader Willi (PW) Syndrome involves the 15th chromosome.
Feeding Problems A feeding problem is defined as the inability to consume adequate food or liquid due to a neuromuscular disturbance. Oral-Motor Problems For the child with any of the oral motor problems (sucking. swallowing. or both. pudding. Behavioral problems include refusal to eat. inability to hold up the head. self-feeding. Some foods such as mashed potatoes. trunk control. and some soups do not require special preparation for a child who has difficulty with chewing. The food is pureed in a food processor or blender. Textures are modified to make eating safe for the child and to stimulate feeding development. crying. Positioning Problems Assessment of positioning problems is usually completed by the physical therapist or occupational therapist and includes observation of head control. • Pureed runny. which alter intake. • Ground The food is ground using a food processor or blender. Students with swallowing problems may require thickened beverages. throwing food on the floor. 2002). swallowing. distractibility during mealtime. foot . so being consistent each day in preparing ground or blended foods is important. Some children have increased sensitivity to food texture. Modification of Food Texture • Chopped -sized pieces with a food chopper. positioning. or chewing) changes in food textures are commonly needed. Self-feeding problems usually include the inability to hold feeding utensils or a cup. behavioral problems. or behavioral. food processor. registered dietitian. and lack of stability of the trunk. or French knife. Preparation of other foods that are difficult to chew may be ordered as part of the physician’s instructions and clarified by the speech therapist. Positioning problems may include the inability to sit in a regular chair. and extreme selectiveness about foods. The oral-motor problems involve sucking. occupational therapist. knife. a small amount of liquid has to be added to avoid dryness and to make it smooth (American Dietetic Association. Feeding problems are usually classified as oral-motor. or parent. In order to puree many foods. oatmeal. and chewing.
Behavioral intervention is the role of the therapist providing small servings. shoulder girdle. and enhances the ability to self-feed. or finding the ideal time and placement of the child in the school cafeteria. or standing. Appropriate positioning varies depending on the problem identified and could include reclining on the stomach. . sitting. knee flexion. spitting out food. placement of the hip and pelvis. Behavioral Issues Behavioral issues may include distractibility during the mealtime and difficulty in completing a meal. or knocking food utensils on the floor. Proper positioning improves visual control by the child. lying on the side. limiting the number of foods served. and sitting base. . refusal to eat.stability. increases food intake since the child may better see the food being offered.
Parents are ready—do they have patience with time involved.1. without support. follow a time schedule HOW TO TRAIN? Use the check list. Find the level to know where. Train the child to eat when he is hungry E. TRAIN IN FEEDING WHEN: A. Train the child to drink when he is thirsty D. B. You will need to be patient. Use appropriate rewards for the child's cooperation and attempts . Rushing her during eating will make her nervous and the movements will become even more uncoordinated C. The child may take quite long in finishing each meal. messiness.Begin to train the child to feed herself when she is able to sit by herself. effort in cleaning up. when and what to train. Understand the problem and have patience to train one step at a time. In case the child is not able to indicate hunger and thirst. Praise the child for the items what he can do.
Sufficient newspaper or large plastic sheet on floor to take care of spillage. Plate should be smaller than dinner plate in order that child may handle it with ease. high-sided plates. Some individualswill require adaptive utensils. however. D. B. etc. the child needs training in how to use these devices. Self-feeding Children with muscle control problems have difficulty in holding a spoon or fork for selffeeding. cut-away cups. There are many devices available for use with these children. or plates (for example: built-up handled utensils. scoop plates. May start with top with perforations. Eating utensils suitable for child-spoon with straight handle or wrapped with cloth or thin piece of plastic foam. Suction cups on bottom of plate or bowl help keep these in place. FIGURE . Spoons with large handles or those wrapped with cloth or thin piece of plastic foam. cups with handles. Graduate from cup to a small glass that child can handle. MATERIALS TO HELP: A. cups. Two-handled mug.).2. Experiment with different shapes and sizes—bend or twist spoon handle to reduce spilling. C. Extra large bib.
If he does not eat. cheese. Fried foods and highly seasoned foods are difficult to digest. cottage cheese on crackers. pork chop bone. the following should be avoided: · grapes · raw vegetables · popcorn · nuts · other round. TYPES OF FOODS: A. Between meal snacks of juice and crackers will not fill the child up for the next regular meal. accept the fact calmly. potato. Finger feeding—solids that can be picked up easily—peanut butter on bread or crackers. Prepare one food with several different methods to see if he will accept it. weiners. G. plain cookie (oatmeal or peanut butter). C.3. toast. celery. bite size pieces of fruits and vegetables (cooked or raw). drumstick with gristle removed. hard foods that do not readily dissolve · peanut butter In addition. D. dry cereal. circle of hard cooked egg. apple. B. Serve all foods attractively and in small quantity. F. Call by name each food eaten and offer new foods at beginning of meal while child is still hungry. E. some feeding practices increase a child’s risk for choking and should be . H. cauliflower. carrots. bacon. bite size pieces of meat. Let the child wait until the next regular meal. Present the same dish three times before you give up on one food and do not make it three consecutive times. except for a small glass of milk or fruit juice. Introduce only one new food at a time and not more often than once a week. For children 4 years and younger. Preventing problems with choking Young children (or older children with delayed feeding skills) are at an increased risk for choking on foods.
seek the guidance of a physiotherapist for exercises for proper arm movements and finger coordination Observe and list out the problems like eating non edible items. paper. Spitting and Vomitting POSSIBLE SOLUTIONS Seek medical help for problems like constipation and indigestion Give activities for finger coordination and arm movement to pick up food and put it in mouth If needed. MECHANICS: GENERAL PROBLEMS Inability to suck and swallow Inability to chew Lack of finger coordination to pick up food Lack of initiation and cooperation Problems in digestion Constipation Does not know how much to eat Does not identify edible items Eating non edible items-mud. chalk etc Spilling. Discourage him from doing such things by giving rewards for appropriate . spilling. spitting and overeating.avoided: · “stuffing” too much food in mouth · running while eating · eating in the car 4.
this is called bite reflex. If the child pushes it with the tongue. SUCKING AND SWALLOWING A child should be able to suck and swallow quite smoothly a few days after birth. keep the child in semi upright position in your arms. if a child lacks good jaw control assit him by using your thumb. A downward stroke on the child's cheek stimulates sucking. warm or cool but not hot or very cold can be given. Mirror may help. place the next spoon full in the side of the mouth. Teach to keep lips closed. Wait to see whether the child's jaw close tightly. Encourage sucking by use of stick candy too hard to be bitten. Proper jaw control is necessary for appropriate sucking and swallowing. Use nipple with regular size hole. Keep a small amount of baby food in a spoon and place it on the baby's tongue. Selection or proper liquids is also important for teaching sucking and swallowing. It also causes choking if the child has difficulty in swallowing. .behaviours. index and middle finger to give support to the jaw. touching the bottom gums. large hole size in a nipple makes a retarded child lazy to suck. CHEWING AND SWALLOWING A normal baby will be able to open his mouth while feeding. The lip and jaw control process should begin before liquid food is placed in the child's mouth. To train in chewing place food in the baby's mouth and observe. Position is important for proper sucking ad swallowing. Pleasant tasting and mildly sweetened juices.
Assist by moving child's jaws up and down and by lightly running finger from chin downward to throat or piece of ice from throat upward to chin and quickly inserting apple sauce or some similar food to be swallowed DEVELOPMENT OF TONGUE MOVEMENTS Observe the child eating notice if the child moves the tongue to touch food at the sides and top of mouth. The doctor may also suggest some lip. tongue and chewing exercises that will help the child to control facial muscles and tongue FINGER FEEDING Make the child sit with necessary support in front of a tray/ table. "hold. requiring the action of retrieval. When the child gains competency loosely mixed food can be introduced.. Observe the child's use of the tongue to retrieve the food. during each feeding. If you note difficultly. and is not necessarily a rejection of food being offered." .e. Train him to grasp to lift hands to mouth and to release it.Pushing the food out of the mouth with the tongue may be an early reflex." "let go. bread and dosa. Sometimes. place his prefered food at the point of mouth. a child may have difficulty in eating or drinking because the saliva drools from the mouth consult a doctor/ health worker child may needs to be given medication. place a small amount of food far back on the tongue or in side of mouth. Start with food items that do not stick in hand such as pieces of chappati. Stand behind child and guide his hand. Gradually add more pieces in the plate. Place one piece at a time in the plate and allow the child to pick up and eat. Encourage child to use lips instead of teeth to remove food from spoon. If u are unable to see tongue movements. To begin. Rice and dal can be mixed and made into small balls and given in the plate allowing the child to pick up and eat. try placing small amount of sticky food (jam) on the roof of the child's mouth near the front and between the cheek and gum. Use simple words of direction: i.
throw. Possibility of better parental attention. K. Avoid making an issue of eating. Do not force him to eat if he is not hungry. Child is not distracted. Begin early to offer a wide variety of food. B. A tired N. etc. C. L. Give him chance to observe the meal time manners F. While learning to feed self. J. OTHER THINGS TO REMEMBER A. H. later on Let the child join the family members during meal time. M. Other members of the family do not express disapproval. and routine. repetition. may do better if he eats alone.Gradually reduce help. Give it to him cheerfully as though you expect he will find it good. I. Don't allow him to get bored with food. Have a restful activity before mealtime so the child will be rested and calm before starting the meal. G. E. child does not want to eat. Use relaxation. . D. Avoid temptation by removing plates when empty—child may bang. Make mealtime pleasant. Do expect him to like each food offered. lick.
Sometimes.Tube Feedings For some children. a child cannot eat safely. Indications for tube feeding can include: · Inability to consume more than 80% of energy or 90% of fluid needs by mouth · Malnutrition (e.. and the child is unable to gain weight with oral feedings. as evidenced by serum albumin. an oral intake is not adequate to meet nutrient needs. or fatigue.g. after surgery or recovery from an acute illness). weight. Sometimes. a child cannot consume enough because of increased needs. Tube feedings are also needed long-term (e. Often the child who is tube fed is severely underweight. .g. Other times. stature) · Repeated upper airway infections (indicating aspiration) · History of gastroesophageal reflux that cannot be managed with medications Tube feedings are frequently ordered for the child with a severe feeding problem that has not improved with the usual oral-motor intervention or if the child cannot swallow without getting food or liquid into the lungs.. skinfold measurements. tube feedings are used for short periods of time (e. oral-motor problems. The nutrient needs of these children are often me t with non-oral enteral feedings (tube feedings). because of oral-motor problems or risk of aspiration because of swallowing difficulties)..g.
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