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retardation refers to substantial limitations in present functioning and it manifests before the age of 18.
is characterized by significantly sub average intellectual functioning, existing concurrently with related limitations in two or more of the following applicable adaptive skill areas:
living social skills community use self-direction health and safety functional academics leisure, and work
retardation (MR) is defined as significant intellectual or cognitive limitations, and an inability to adapt to the demands of everyday life. (Sheerenberger (1983))
retardation (MR) refers to significantly sub average general intelligence that causes major difficulties in activities of daily living, and has manifested by age 18.
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 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
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 )
support Limited support Extensive support Pervasive support
is formally diagnosed by professional assessment of intelligence and adaptive behaviour.
DSM –IV diagnostic criteria
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, selfhelp 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)
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
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
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
disorder Neurofibromatosis( neurocutaneous syndrome characterised by ‘cafe au lait spots’, optic gliomas and acoustic neuromas) Adrenoleukodystrophy Maple syrup urine disorder
II. ACQUIRED AND DEVELOPMENTAL FACTORS prenatal period
chronic illness Uncontrolled diabetes Anaemia Emphysema Hypertension Long term use of alcohol and narcotic substance Viral infections
prenatal period Cont…
(German measles) Cytomegalic inclusion disease Syphilis Toxoplasmosis Herpes simplex AIDS Foetal alcohol syndrome Prenatal drug exposure Complication of pregnancy
childhood disorder Infections Iodine deficiency Head trauma Near Drowning Cardiac arrest ( during anaesthesia )
perinatal period cont…
term exposure of lead Exposure to mercury Intracranial tumours Surgery chemotherapy
III. ENVIRONMENTAL AND SOCIOCULTURAL FACTORS
instability Teenage pregnancies Mental disorder in parents
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.
Behavioural disturbances Aggression Self-injury Defiance (disambiguation) Inattention Hyperactivity Anxiety Depression Sleep disturbances
Behavioural disturbances cont…
behaviours Difficult temperaments Noncompliance Hyperactivity Disordered sleep Colic Poor social skills Delays in play skills.
expressive language •lack of expressive language
Fine motor/adaptive delay
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
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
and physical examination DNA analysis Karyotype at the 500 band level of resolution Plasma amino acids Urinary organic acids Urinary muco-polysaccharides and oligosaccharides
7-DHC (Smith-LemliOpitz syndrome) Thyroid function tests Very-long-chain fatty acids Creatine kinase
MRI Head CT scan Skeletal films
Scales of Infant Development ◦ Normalized for ages 2-30 months ◦ Subtest scores for receptive and expressive language, nonverbal problem-solving ability, and sustained attention
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
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
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
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
if clinically warranted Auditory evoked potentials in the context of audiologic assessment Visual evoked potentials in cases of profound delay and suspected cortical blindness
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
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
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
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.
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