case study on mental retardation

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• Cerebral Palsy

Mental Retardation

• Attention Deficit Hyperactivity Disorder
• Down’s Syndrome
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• Multiple Sclerosis

Krishna* (Male, 29 Years)

Before: He has been diagnosed with Moderate Mental Retardation – IQ – 45.7%;  75% disability. He is on medication for hyperactivity. He would not be able to sit for long period of time. His comprehension levels were low. His ability to focus and learn was affected. His fine motor coordination suffered the most. His ability to write would suffer. His body would quiver whenever he needed to manipulate things. His hand eye coordination was not very good.

After: After Six months of treatment his hyperactivity has reduced considerably. He is much calmer than before. His sitting tolerance has improved. His overall comprehension is better. Parents report that he is able to understand things takes responsibility and is discreet about discussing things with people. He is also able to understand instructions and execute them better than before. His tremble has improved and he is much more confident in climbing stairs and handling things. His hand-eye coordination has improved. He is much more confident in catching foot ball during the games period.

*Names are changed to maintain confidentiality

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• Intellectual Disability
• Author: Ari S Zeldin, MD, FAAP, FAAN; Chief Editor: Stephen L Nelson, Jr, MD, PhD, FAACPDM, FAAN, FAAP, FANA  more...
• Sections Intellectual Disability
• Practice Essentials
• Pathophysiology
• Mortality/Morbidity
• Laboratory Studies
• Imaging Studies
• Other Tests
• Histologic Findings
• Approach Considerations
• Medical Care
• Consultations
• Long-Term Monitoring
• Medication Summary
• CNS stimulants
• Alpha-adrenergic agonists
• Neuroleptic drugs (antipsychotics)

Intellectual disability (ID), is a descriptive term for subaverage intelligence and impaired adaptive functioning arising in the developmental period (< 18 years).

Signs and symptoms

Patients with ID and developmental delays may demonstrate the following:

Language delay: One of the first signs of ID may be language delays, including delays in expressive language (speech) and receptive language (understanding)

Fine motor/adaptive delay: Significant delays in activities such as self-feeding, toileting, and dressing are typically reported in children with ID

Cognitive delay: Difficulties with memory, problem-solving, and logical reasoning

Social delays: Lack of interest in age-appropriate toys and delays in imaginative play and reciprocal play with age-matched peers

Gross motor developmental delays: Infrequently accompany the cognitive, language, and fine motor/adaptive delays associated with ID unless the underlying condition results in both ID and cerebral palsy.

Behavioral disturbances: Infants and toddlers may be more likely to have difficult temperaments, hyperactivity, disordered sleep, and colic; associated behaviors may include aggression, self-injury, defiance, inattention, hyperactivity, sleep disturbances, and stereotypic behaviors.

Neurologic and physical abnormalities: Prevalence of ID is increased among children with seizure disorders, microcephaly, macrocephaly, history of intrauterine or postnatal growth retardation, prematurity, and congenital anomalies

Evaluation of patients for ID can include the following examinations:

Head circumference: Microcephaly correlates highly with cognitive deficits; macrocephaly may indicate hydrocephalus, is associated with some inborn errors of metabolism, and may be seen early on in some children later diagnosed with autism [ 1 , 2 ]

Height: Short stature may suggest a genetic disorder, fetal alcohol syndrome, or hypothyroidism; tall stature may suggest fragile X syndrome (FraX), Soto syndrome, or some other overgrowth syndrome associated with ID

Neurologic: This examination should include assessments of head growth (for microcephaly/macrocephaly), muscle tone (for hypotonia or spasticity), strength and coordination, deep tendon reflexes, persistent primitive reflexes, ataxia, and other abnormal movements, such as dystonia or athetosis.

Sensory: Children with disabilities and ID are more likely than other children to have visual impairment and hearing deficits

Skin: Findings can include hyperpigmented and hypopigmented macules, such as café-au-lait macules (associated with neurofibromatosis type 1), as well as ash-leaf spots (associated with tuberous sclerosis), fibromas, and irregular pigmentation patterns

Extremities: Although ID with multiple congenital anomalies and major malformations accounts for only 5-10% of all cases, most of these affected individuals have 3-4 minor anomalies, especially involving the face and digits

See Clinical Presentation for more detail.

Laboratory studies

Array-based comparative genetic hybridization (CGH), or microarray

High-resolution karyotype

Fragile X testing

FISH probes

Next-generation sequencing through panels and/or whole exomes

Imaging studies

Brain magnetic resonance imaging (MRI): Should be conducted in any child with global developmental delays or ID [ 3 ]

Head computed tomography (CT) scanning: Preferred imaging study for calcifications that may be identified with TORCH infections (ie, toxoplasmosis, other infections, rubella, cytomegalovirus [CMV], herpes simplex) or when tuberous sclerosis is suspected or craniosynostosis is a concern

Skeletal films: Assist with phenotypic description, syndrome characterization, and assessment of growth

Additional tests

Detailed assessment by a licensed professional is necessary to confirm the diagnosis of ID. Some of the most commonly used tests in children include the following:

Bayley Scales of Infant Development

Stanford-Binet Intelligence Scale

Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R)

Wechsler Intelligence Scale for Children–IV (WISC-IV)

Vineland Adaptive Behavior Scales-II

See Workup for more detail.

The mainstay of ID treatment is the development of a comprehensive management plan for the condition. The complex habilitation plan for the individual requires input from care providers from multiple disciplines, including special educators, language therapists, behavioral therapists, occupational therapists, and community services that provide social support and respite care for families affected by ID.

Neuropathic pain due to dysautonomia or motor spasms may create chronic disturbances. Treatment should be prompt and include the following:

Nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen for mild pain

Tramadol or equivalent for moderate pain

Opioids for severe pain as indicated

Management of sources of pain

No specific pharmacologic treatment is available for cognitive impairment in the developing child or adult with ID. [ 4 ] Medications, when prescribed, are targeted to specific comorbid psychiatric disease or behavioral disturbances.

The psychostimulant class of drugs is commonly prescribed in individuals with ID, because of the diagnosis of attention deficit with or without hyperactivity disorder (ADHD/ADD) in 6-80% of these patients. However, few studies on stimulants in people with ID are available. The studies that do exist indicate that benefits vary, and significant adverse events, such as severe social withdrawal, increased crying, drowsiness, and irritability, have been noted, especially at higher doses of methylphenidate (0.6 mg/kg). [ 5 ]

The neuroleptic drugs are the most frequently prescribed agents for targeting behaviors such as aggression, self-injury, and hyperactivity in people with ID. These indications are generally off-label for ID and caution is advised.

See Treatment and Medication for more detail.

Intellectual disability (ID) is a descriptive term for subaverage intelligence and impaired adaptive functioning arising in the developmental period (< 18 y). ID and other neurodevelopmental disabilities are seen often in a general pediatric practice.

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5) , characterizes ID by deficits in general mental abilities, such as reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience. The deficits result in impairments to adaptive functioning, such that the individual fails to meet standards of personal independence and social responsibility in one or more aspects of daily life, including communication, social participation, academic or occupational functioning and personal independence at home or in community settings. [ 6 ]

Approximately 10% of children have some learning impairment, while as many as 3% manifest some degree of ID. The population prevalence of these combined disorders of learning rivals that of the common childhood disorder asthma.

ID originates during the developmental period (i.e., conception through age 18 years). ID is categorized as a neurodevelopmental disorder and is distinct from the neurocognitive disorders, which are characterized by a loss in cognitive functioning. Major neurocognitive disorder may occur with ID such as when an individual with Down syndrome develops Alzheimer's disease, for example. In a case like this, both ID and neurocognitive disorder would be diagnosed.

ID also can be categorized as syndromic, if associated with dysmorphic features, or nonsyndromic, if not associated with dysmorphisms or malformations. The understanding of specific ID syndromes is expanding with recent molecular genetic advances. More than 800 recognized syndromes listed in the Online Mendelian Inheritance in Man (OMIM) database are associated with ID, reflecting clinical diagnostic advances in the field. The most common associated chromosomal abnormality is trisomy 21, or Down syndrome . The most common X-linked abnormality associated with ID is fragile X syndrome . However, for most cases of ID, no specific genetic abnormalities are found.

Some forms of ID are due to nongenetic factors and may be identifiable by their associated dysmorphisms and clinical presentation. Examples include prenatal exposure to teratogens (e.g., anticonvulsants, warfarin, alcohol) or prenatal thyroid dysfunction. Prenatal and postnatal exposure to lead and the associated decrement in IQ may increase an individual's chance of functioning in the ID range. ID may result from an acquired infection or injury during the developmental period from, for example, a severe head injury or meningitis or encephalitis infection

Diagnostic criteria (DSM-5)

Intellectual disability (intellectual developmental disorder) is a disorder with onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social and practical domains. According to the DSM-5 , the following three criteria must be met: [ 6 ]

Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience, confirmed by both clinical assessment and individualized, standardized intelligence testing.

Deficits in adaptive function that results in failure to meet developmental and sociocultural standards for personal independence and social responsibility. Without ongoing support, the adaptive deficits limit functioning in one or more activities of daily life, such as communication, social participation, and independent living, across multiple environments, such as home, school, work, and community.

Onset of intellectual and adaptive deficits during the developmental period.

Severity is specified as mild, moderate, severe, or profound based on the level of impairment in adaptive functioning, and not IQ scores, because it is adaptive functioning that determines the level of support required. The three domains of adaptive functioning are conceptual, social, and practical.

In addition to severity, the specifier “associated with a known medical or genetic condition or environmental factor” may be given. Examples include genetic disorders, such as fragile X syndrome, tuberous sclerosis, and Rett syndrome; and environmental factors including fetal alcohol exposure (even in the absence of fetal alcohol syndrome).

Intellectual disability (ID) is the end result of many disorders of CNS function. Most individuals with significant intellectual impairment have no discernible structural abnormalities of the brain. CNS malformations, a visual correlate of the disorders, are diagnosed in 10-15% of cases; dysfunction is localized primarily to the cortical structures, including the hippocampus and the medial temporal cortex. The most common malformations consist of neural tube defects, hydranencephaly, and microcephaly. Less commonly, CNS malformations include disorders of migration (the lissencephalies) and agenesis of the corpus callosum.

Multiple congenital anomaly syndromes with malformations confined to nonneurologic organ systems may be present in 5% of all patients with ID. Between 3% and 7% of cases may be associated with a wide array of inborn errors of metabolism complicated by multiorgan system disease. Alcohol exposure in utero may account for as many as 8% of those with mild ID.

Most individuals with mild ID and other learning disorders do not have other neurologic complications, CNS malformations, or dysmorphisms. They are more likely, however, to be born into families of low socioeconomic status, low IQ, and little education. The etiologic contribution of poverty to their poor cognitive function remains unclear. Clearly, however, poor cognitive functioning and ID are correlated positively with a life of poverty.

United States

The frequency of intellectual disability (ID) of all degrees ranges from 1% to 3% of the population. ID has an overall general population prevalence of approximately 1% and prevalence rates vary by age. Prevalence for severe intellectual disability is approximately 6 per 1,000. [ 6 ]

International

A study with excellent ascertainment conducted in Aberdeen, Scotland, yielded a prevalence of 1 in 300 for severe ID and 1 in 77 for mild ID. Among those with severe ID were more boys than girls (male-to-female ratio 1.2:1), and among those with IQ > 70, in the mild range of deficiency, boys exceeded girls by a ratio of 2.2:1. [ 7 ]

Although prevalence rates vary from country to country, the variance in prevalence may be attributed to ascertainment bias, the standardization methods employed from study to study, and a generalized upward drift in IQ scores over time. Even so, the greatest variance in statistics of prevalence is most likely to fall within the category of mild ID, a group for which the ascertainment bias is large.

Race-, sex-, and age-related differences in incidence

Consistent racial differences in prevalence of ID and associated mortality rates are not known to exist.

The gender ratios for mortality and morbidity do not differ from the gender ratio noted in the severe/profound ranges of intellectual disability (ie, male-to-female ratio, 1.2:1).

ID refers to intellectual impairment that develops prior to the age of 18 years.

Certain syndromes associated with ID, such as Down syndrome, are associated with shorter life expectancy than the general population. In a comparison of those with ID with and without Down syndrome from the California Department of Developmental Services cohort, excess mortality in the Down syndrome group tended to decrease with advancing age up to 35-39 years but increased thereafter. The increase in death rate from age 40 years was steeper in patients with Down syndrome than in those without Down syndrome. [ 8 ]

Intellectual disability (ID) itself is not necessarily associated with an increased premature death rate. However, individuals with severe to profound ID experience a decreased life expectancy related to the underlying etiology or additional complicating neurologic disorders, such as epilepsy. Neurologic dysfunction resulting in immobility, significant oral motor incoordination, dysphagia, and aspiration confers a greater risk of premature death than ID itself. When significant neurologic dysfunction is associated with other organ system anomalies, an individual's life expectancy is shortened further.

Respiratory disease is the most prevalent cause of death among individuals with profound ID. In particular, respiratory infections were the leading cause of death among a Finnish cohort of children with ID. [ 9 ] For those affected by mild ID, life expectancy does not differ from that of the general population.

Comorbid psychiatric conditions are diagnosed more frequently in those with intellectual disabilities than in the general population. Even so, psychiatric disorders probably are underappreciated in this population.

Attention deficit/hyperactivity disorder (ADHD) is diagnosed in 8-15% of children and 17-52% of adults with ID.

Self-injurious behaviors require treatment in 3-15%, particularly in the severe range of ID.

Major depression, bipolar disorders, anxiety disorders, and other mood disorders are the most common psychiatric diagnoses in adults with ID. Obsessive-compulsive disorder, conduct disorder, tic disorders, and other stereotypic behaviors are also diagnosed more commonly in those with ID. Schizophrenia may have a prevalence of 3% in individuals with ID, compared to 0.8% in the general population.

In the 1970 Isle of Wight study, as many as 30% of children with ID exhibited an emotional or behavioral disorder, compared to 6% of children in the general population. ID compounded by epilepsy conferred a 56% risk of comorbid psychiatric disease in this study. [ 10 ]

Occult visual and auditory deficits occur in 50% of those with ID, particularly when refractive errors are considered.

The rates of transmittable diseases, including sexually transmitted diseases (STDs), hepatitis B, and Helicobacter pylori infection, are increased significantly among individuals with ID.

One in 5 individuals with ID also has cerebral palsy (CP).

As many as 20% of individuals with ID have seizures.

GI complications with ID include feeding dysfunction, excess drooling, reflux esophagitis, and constipation.

GU complications with ID include urinary incontinence and poor menstrual hygiene.

A profound social morbidity affects individuals with ID and their families. This morbidity can be measured in lost wages, dependence on social services, impaired long-term relationships, and emotional suffering.

Individuals with a diagnosis of intellectual disability with co-occurring mental disorders are at risk for suicide. Screening for suicidal thoughts is essential in the assessment process.

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Contributor Information and Disclosures

Ari S Zeldin, MD, FAAP, FAAN Staff Pediatric Neurologist, Naval Medical Center San Diego Ari S Zeldin, MD, FAAP, FAAN is a member of the following medical societies: American Academy of Neurology , American Academy of Pediatrics , Child Neurology Society Disclosure: Nothing to disclose.

Alicia T F Bazzano, MD, PhD, MPH Clinical Faculty, Division of Pediatric Emergency Medicine, Harbor/UCLA Medical Center; Chief Physician, Westside Regional Center Alicia T F Bazzano, MD, PhD, MPH is a member of the following medical societies: Alpha Omega Alpha , American Academy of Pediatrics , American Public Health Association , American Society for Bioethics and Humanities Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.

Stephen L Nelson, Jr, MD, PhD, FAACPDM, FAAN, FAAP, FANA Professor of Pediatrics, Neurology, Neurosurgery, and Psychiatry, Medical Director, Tulane Center for Autism and Related Disorders, Tulane University School of Medicine; Pediatric Neurologist and Epileptologist, Ochsner Hospital for Children; Professor of Neurology, Louisiana State University School of Medicine Stephen L Nelson, Jr, MD, PhD, FAACPDM, FAAN, FAAP, FANA is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine , American Academy of Neurology , American Academy of Pediatrics , American Epilepsy Society , American Medical Association , American Neurological Association , The Society of Federal Health Professionals (AMSUS) , Child Neurology Society , Southern Pediatric Neurology Society Disclosure: Nothing to disclose.

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Karen H Harum, MD to the development and writing of this article.

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The Study on the Psycho-social Issues and Challenges of Children with Mental Retardation: A Case Study

2017, Sociology and anthropology

A lot has been written about the psycho-social issues and challenges of children with mental retardation. The aim of this research is to investigate the impact of psycho-social issues and challenges of children with mental retardation. The study utilized qualitative research tools to explore the deep feelings of the participants. Purposive sampling technique and case study employed as a major study tools. The study used in-depth interview, observation and FGD. The collected data were organized and analyzed through qualitative research approach by using thematic analysis. Findings obtained from the study showed that children with mental retardation are facing different psychosocial challenges like stigma, discrimination, isolation, blame, shame, frustration, feeling of upset, self-insult, loneliness, losing respect, despairing (feeling of no hope), insult, anger and sadness. The study also found that the perception parents of children with mental retardation regarding the causes of r...

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vasantha kumari c

International Journal of Public Health Science (IJPHS)

Mental Retardation is a condition in which the intelegency function is under average, which began during the developmental period. Children with mentally retarded have limited mental function, communication skills, ability to maintain themselves and social skills. These conditions impact the mothes’s they responsible to train children’s ability to be independent. The purpose of this study is to explore the mothers’ experience having children with mental retardation at Special School for mentally retarded (SLB) of Karya Ibu Palembang, Indonesia. This is a qualitative research with fenomenology approach from five partisipants with indept interview. Five themes were get including can’t accept reality, burden, the social stigma, need support from relatives, worry about the future, and admitting God’s will. The Adaptation behaviors found in this study are the acceptance of children’s condition, and loving the children thoroughly.

International Journal of Management, Technology, and Social Sciences (IJMTS)

Srinivas Publication

Down the ages, we see disability is as curse or punishment. With the development of science and social change, disability is seen as a societal problem rather than individual problem and solution became focused on removing the barriers to social change, not just medical care. The persons with a disability encounter discrimination; they tend to alienate themselves from society as they feel unwanted and rejected. It affects the psycho social condition of persons with disabilities. The human person is a complex entity composed of two distinct phenomena, the physique, and the psyche, commonly called body and mind [1]. It is both common knowledge and scientific theory that a person's mental life and emotional reactions are influenced by his physical condition as well as his social and physical environment [2]. This research paper aims to present Psycho-Social problems faced by a person with a disability. And the objectives are to study the profile of the physically disabled and psycho social problems of the disabled. This study is descriptive in nature where data is collected from both primary and secondary source. 25 respondents were selected for the study and interview schedule is used to collect information.

Kyla Oliver

Disability does not mean lack of something. It means that despite of not having something, one can still do things. Humans are imperfect, which means one does not need to have an attitude that is judgemental and accusatory. Disability does not alienate but the attitudinal character of the people who perceive disability as a limitation and imperfection. This research is about the attitudinal character of the students with disability who struggle in their social and community life in a daily basis. The said research is both explanatory and expository using one-on-one interview with the participant. The said research focused on a certain person with special needs are being catered and taught along with other normal students.

International Journal of Advanced Psychiatric Nursing

ALFRED SOLOMON

robert podstawski

Purpose: The aim of this work is to assess the relationship between the environment and mentally retarded persons. Material and methods: Information referring to social support of mentally retarded persons is a source material collected on the base of the data included in the Polish and foreign literature. The issues under discussion related to the following problems: social integration of persons with intellectual disabilities in a family and local environment, social functioning of people with mild intellectual disability, social rehabilitation of people with moderate, severe and profound intellectual disability and specific contact with people with disabilities. Results: For a person with an intellectual disability, the family is the source of acquisition of basic social skills that give him the opportunity for further development and performing certain social roles in a sense of safety. Full acceptance of the intellectually disabled, may dismiss their sense of shame and fear, an...

International journal of advanced psychiatric nursing

Zinat Mohebbi

Journal of ICSAR

Attitude is a form of response that a person gives to something he sees. The purpose of this study was to find out how the community&#39;s attitude towards the social life of mentally retarded adolescents in Paninggilan Village. This research use qualitative descriptive approach. The respondents of this study were the community, which consisted of 10 people and 1 parent of a mentally retarded teenager. Data were collected through observations, interviews, documentation and field notes. The data analysis used was data reduction, data presentation and conclusion drawing. The results showed that the attitude of the community towards the social life of mentally retarded adolescents in Paninggilan Village could not be said to be completely good. When viewed based on the 3 components of the attitude acceptance aspect, the community already knows and understands a little what children with special needs are, the attitude given by the community to mentally retarded adolescents in Paninggila...

Vladimira Polackova

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• v.18(1); Jan-Jun 2009

Social development of children with mental retardation

Indrabhushan kumar.

Subdivisional Hospital, Pusa, Samastipur (Bihar) - 848 125, India

Amool R. Singh

1 Department of Clinical Psychology, Ranchi Institute of Neuro Psychiatry and Allied Sciences, Kanke, Ranchi - 834006, India

2 Chief Medical Officer, Central Institute of Psychiatry, Kanke, Ranchi, Jharkhand - 834 006, India

Background:

Social development of children with mental retardation has implications for prognosis. The present study evaluated whether the social maturity scale alone can reflect on the social maturity, intellectual level and consequent adjustment in family and society of children with mental retardation.

Materials and Methods:

Thirty-five mentally retarded children were administered Vineland Social Maturity Scale and Stanford Binet Intelligence Scale.

It was found that there was significant relationship between the measures of social maturity scale and the IQ of the subjects. Further it was found that with increasing severity of retardation, social development also decreases and age does not have any effect on social development.

Conclusion:

Social quotient increases from profound to mild level of retardation.

Mental retardation (MR) is one of the most distressing handicaps in any society. Development of an individual with mental retardation depends on the type and extent of the underlying disorder, the associated disabilities, environmental factors, psychological factors, cognitive abilities and comorbid psychopathological conditions (Ludwik, et al ., 2001). Social development means acquisition of the ability to behave in accordance with social expectations (Pati et al ., 1996). Becoming socialized involves 3 processes: i) learning to behave in socially approved ways, ii) playing approved social roles and iii) development of social attitudes (Hurlock, 1967). For people with mental retardation, their eventual level of social development has implication for the degree of support needed in their literacy arrangement and their integration in the community with increasing emphasis on mainstreaming the attainment of skills in personal, domestic and community functioning. It also contributes considerably to quality of life. Thus investigation of factors that may facilitate or inhibit social development assumes particular importance.

Mentally retarded children, due to low intellectual growth, function with a limited capacity in comparison to normal children. Hence the social functioning of these children is found to be affected, and this is closely related to degree of impairment. In addition to brain pathology, there are other factors related to the malfunctioning of these children in a normal social setup. A particular environmental setup in which a child grows up is likely to play an important part in improving or deteriorating the child’s functioning in a social milieu. Shastri and Mishra (1971) assessed 56 school-going children (aged 6-13 years) with mental retardation with the help of Social Maturity Scale and found that the mentally retarded children function more in the lower level of social interaction. As the degree of impairment in terms of intelligence goes down, it is observed that the child approaches an average or satisfactory level of social functioning. They also found that the level of social development varies with the intellectual level among persons with mental retardation, or a wide range of family and environmental variables may also influence social development. Pati et al ., (1996) designed a study to identify the effects of severity of retardation, age, type of services attended and location of services in rural/urban area on the social development of children with mental retardation using a sample of 113 subjects diagnosed as children with mental retardation. The analysis of results suggested that with increasing severity of retardation, social development also decreases. Further it was found that age, type of services and location of center do not have any effect on social development. Mayers et al ., (1979) found that a positive relationship exists between measures of adaptive behavior and IQ or mental age. Cornbell et al ., (1969) assessed relationship between social and cognitive functioning. For people with Down’s syndrome, the level of social functioning was found to exceed the level of cognitive functioning. Matson et al ., (1999) designed a study to identify the effects of seizure disorders/epilepsy on psychopathology, social functioning, adaptive functioning and maladaptive behaviors using a sample of 353 people diagnosed with a seizure disorder and either severe or profound intellectual disability. People with a diagnosis of seizure disorder were found to have significantly less social and adaptive skills when compared to developmentally disabled controls with no seizure disorder diagnosis. In the light of the above investigation, the present study was designed with the following aims: (1) to find out the effects of severity of mental retardation on social development, along with possible correlation with social quotient (SQ) and IQ, which will eventually help in formulating appropriate training management and rehabilitation of mentally retarded children; and (2) to find out the relationship between age and social development.

MATERIALS AND METHODS

The present study was carried out on a sample of 35 mentally retarded children (mean age, 14.17 years; SD, 5.5) chosen at random from the Central Institute of Psychiatry, Kanke, Ranchi (Jharkhand). The sample included 19 males and 16 females. Children with comorbid epilepsy, sensory deficit (like impairment of vision, hearing), other psychiatric disorders and physical problems were excluded. Characteristics of the study population are given in Table 1 .

Characteristics of the study population

Figures in parentheses indicate percentage

Specially designed socio-demographic data sheet

A format was developed to record the background information about the subject, like name, age, sex, level of retardation/epilepsy, etc.

Vineland social maturity scale (Nagpur adaptation)

The scale was originally developed by E. A. Doll in 1935, which was then adapted by Dr. A. J. Malin in the year 1965. It measures differential social capacity of an individual. It provides an estimate of social age (S.A.) and social quotient (SQ) and shows high co-relation (0.80) with intelligence. It is designed to measure social maturation in 8 social areas. The scale consists of 89 items grouped into year levels (13 age groups). It can be used for the age group of ‘below 15 years’; it means from birth to 15 years.

Stanford Binet intelligence scale (Hindi adaptation)

It was originally developed by Alfred Binet with the help of Simon in 1905 in France. In India its Hindi version was developed by S. K. Kulshrestha. Its 1960 revision has a range of 2 years to 22 years and 11 months of mental age scores. The single Binet L-M form is available with norms on data as recent as 1972. This form measures abilities in 7 categories: Languages, reasoning, memory, social intelligence, conceptual, numerical reasoning and visual motors. Test items are in the form of words, objects and pictures, and responses given by the testees are in the form of drawing, calculating, writing and speaking. In this revision, the intelligence is expressed in terms of standard score of intelligence, IQ.

Mentally retarded children were identified on the basis of International classification of disease 10 th revision (Diagnostic criteria for research). Informed consent was taken from the informants before eliciting relevant information, and the nature and purpose of the study were explained. All subjects who were selected for the present study were interviewed and then assessed for IQ with the help of Stanford Binet Intelligence Scale. Thereafter, Vineland Social Maturity Scale was administrated to know the level of social development of each subject.

Analysis of data

Data has been analyzed using means, standard deviations, Kruskal-Wallis (nonparametric) one-way ANOVA test, chi-square test and Pearson correlation on social quotient.

RESULTS AND DISCUSSION

One-way analysis of variance was carried out to find out if there was any significant difference in social development in relation to various levels of mental retardation [ Table 2 and Figure 1 ].

Difference in social development in relation to various levels of mental retardation

Social development in relation to various levels of mental retardation

The value of ANOVA was significant at. 01 level (χ 2 = 14.9; df = 3). This indicates that there were statistically significant differences in the social developments of children in relation to various levels of mental retardation; with degrees of social development (in terms of SQs) for mild, moderate, severe and profound retardations being 59.4, 42.1, 30.8 and 19.0, respectively, and the standard deviations being 20.3, 14.4, 8.6 and 9.5, respectively. This suggests that there are significant differences in the social development of each category of retardation. It is observed that with increasing severity of mental retardation, the level of social development decreases. The findings strongly suggest that among children with mental retardation too, the cognitive and social skills are interrelated. The intellectual development and social development go together in the same direction. Similar observations were reported by Pati et al ., (1996).

Computed value of correlation of social quotient in different age groups was -0.17, which is not significant statistically; this may indicate the stability of social quotient with increasing age [ Table 3 ].

Correlations among age, IQ and social development

Computed value of Pearson correlation coefficient between IQ and SQ was .785, which is significant. This may indicate relationship between IQ and SQ, i.e., relationship between intellectual capacity and social development [ Table 3 ].

This study shows that as the level of mental retardation increases, social development decreases correspondingly. There was no impact of the age factor on the social development of mentally retarded children. Most of the people think that as the child grows, social development will be enhanced; today, he is a child; tomorrow he will be socially developed. This study will make the parents of mentally retarded children aware about the functional requirement of counseling for the mentally retarded children. If the degree of mental retardation is more, the need for special education and training will be more intense. Similarly, for those who have a lesser IQ, there will be greater requirement of special training. Most of the parents feel it is futile to spend money for the social development of severe and profound mentally retarded children; this expense will have no utility, and so why not utilize such money for normal children? This study will be helpful in making people aware about the necessity of training, managing and rehabilitating children with mental retardation. Right from the very beginning, there is an effective role for parents, teachers and other professionals in the enhancement of social skills of mentally retarded children. This study opens the path for research to determine whether there is any impact of special education and training on the social development of mentally retarded children of various age groups.

Because of time constraints and excessive workloads, trained psychologists are unable to assess the IQ, as the number of clinical psychologists throughout India is about 600-700 (Nathawat et al ., 2001). Therefore, other methods are required for IQ assessment. Among the various techniques, social development scale is a very important method to determine one’s IQ. This social development scale is relatively easy to administer and has practical application in the assessment of IQ. It has also been found important in the management of disabled persons. SQ and IQ are highly correlated (.80) on the Stanford Binet Intelligence Scale; and the same has been found in the index study as well. Magnitude of MR is known by SQ where IQ testing is not possible. Many clinicians use social development scale in their clinics for children and adolescents as it is a valuable device for interviewing and counseling both parents and children.

It can be concluded that the social quotient increases as level of mental retardation decreases from profound to mild. The social quotient across different age ranges does not differ significantly. Clinical psychologists who are working with underprivileged children/individuals may use the Vineland Social Maturity Scale as a rapid screening test for determining IQ and capacity for social adjustment.

Source of Support: Nil

Conflict of Interest: None declared.

DONNA K. DAILY, M.D., HOLLY H. ARDINGER, M.D., AND GRACE E. HOLMES, M.D.

This is a corrected version of the article that appeared in print.

Am Fam Physician. 2000;61(4):1059-1067

See related patient information handout on mental retardation , written by the authors of this article .

Mental retardation in young children is often missed by clinicians. The condition is present in 2 to 3 percent of the population, either as an isolated finding or as part of a syndrome or broader disorder. Causes of mental retardation are numerous and include genetic and environmental factors. In at least 30 to 50 percent of cases, physicians are unable to determine etiology despite thorough evaluation. Diagnosis is highly dependent on a comprehensive personal and family medical history, a complete physical examination and a careful developmental assessment of the child. These will guide appropriate evaluations and referrals to provide genetic counseling, resources for the family and early intervention programs for the child. The family physician is encouraged to continue regular follow-up visits with the child to facilitate a smooth transition to adolescence and young adulthood.

The diagnosis of mental retardation in young children is frequently missed. The three most common errors made by clinicians who overlook the possibility of mental retardation are (1) concluding that a child does not “look” retarded, (2) assuming that a child who is ambulatory is unlikely to be retarded and, (3) if retardation is actually considered, concluding that it is not possible to test young children. 1

Mental retardation is present in about 2 to 3 percent of the population. It can be defined as cognitive ability that is markedly below average level and a decreased ability to adapt to one's environment. The onset of the condition occurs during the developmental period, i.e., gestation through age 18 years.

Mental retardation comprises five general categories: borderline, mild, moderate, severe and profound. Categories are based on scores obtained through use of age-standardized tests of cognitive ability ( Table 1 ) . 2 Mental retardation may occur as part of a syndrome or broader disorder but is most commonly an isolated finding.

The inclusion of concurrent related limitations in two or more adaptive skill areas was added to the definition of mental retardation in 1992 by the American Association on Mental Retardation. 3 Because standardized testing in very young children is less predictive of future cognitive outcome, the term “developmental delay” has been used to characterize the developmental status of children under age three.

A number of environmental, genetic or multiple factors can cause mental retardation. Unfortunately, in approximately 30 to 50 percent of cases, the etiology is not identified even after thorough diagnostic evaluation. 4 , 5 Some persons have a congenital malformation of the brain; others had damage to the brain at a critical period in pre- or postnatal development. Acquired causes of retardation include near-drowning, traumatic brain injury and central nervous system malignancy.

Prenatal causes of mental retardation include congenital infections such as cytomegalovirus, toxoplasmosis, herpes, syphilis, rubella and human immunodeficiency virus; prolonged maternal fever in the first trimester; exposure to anticonvulsants or alcohol; and untreated maternal phenylketonuria (PKU). Complications of prematurity, especially in extremely low-birth-weight infants, or postnatal exposure to lead can also cause mental retardation. 6

Metabolic disorders are another possible cause of mental retardation. In some cases (e.g., PKU, hypothyroidism), retardation is preventable with early treatment. Other disorders (e.g., mucopolysaccharidosis, sphingolipidoses) are less responsive to early intervention. Molecular medicine has made it possible to diagnose a number of conditions referred to as mitochondrial cell diseases. 7

A number of single-gene disorders result in mental retardation. Many of these are associated with atypical or dysmorphic physical characteristics. Such conditions include fragile X syndrome, neurofibromatosis, tuberous sclerosis, Noonan's syndrome and Cornelia de Lange's syndrome. A complete list of syndromes associated with mental retardation is beyond the scope of this article, and the reader is referred to the reference list. 8 , 9

As many as one fourth of persons with mental retardation have a detectable chromosome abnormality. Children with Down syndrome (trisomy 21) usually have highly recognizable physical characteristics, but features associated with other chromosomal abnormalities, such as Klinefelter's syndrome (47,XXY), may not be as obvious to family members or the physician. Other children may have a small deletion or duplication of a particular chromosome that is rarely reported; thus, the phenotype is still undetermined. Some chromosomal abnormalities are inherited from a parent but most occur de novo. Many previously described clinical syndromes have been found to have an associated chromosomal abnormality (e.g., DiGeorge, Prader-Willi, Angelman and Williams syndromes).

The following case report highlights the importance of early diagnosis, in planning therapy for the child and in providing family planning information to the parents.

Illustrative Case

A 16-month-old boy was referred for developmental assessment because he was not yet talking.

He was born to a 30-year-old woman, gravida 2, para 2, living children 2. He was delivered at term by cesarean section with no prenatal, labor or postnatal complications. He was slightly blue at birth and required oxygen. Mother and infant went home in two days, and no other newborn problems were noted. Birth weight was 3.2 kg (7 lb, 1 oz). The infant was breast-fed for about 12 months. Solid foods were added at 10 months, but some difficulty was noted with chewing. The boy rolled over at three to four months, sat without support at seven months and crawled at seven to eight months. He began to walk at 16 months but still did not talk. The mother first became concerned about lack of speech when the child was 13 months old. The remainder of the medical history, the review of systems and the family history were noncontributory.

At 16 months, the child's height and weight were less than the 5th percentile; head circumference was at the 25th percentile. The child was pleasant, alert, active and cooperative. No vocalization of any kind was noted during the examination. Physical findings included a slightly prominent forehead with a depressed wide nasal bridge and a flat nose. The midface appeared depressed; the child's face closely resembled his mother's. The only other abnormal finding was a small left testis. The boy could stand for a few seconds without support and was able to take a few steps. His muscle tone was mildly low but within the reference range.

The physician's impressions included the following: midface hypoplasia, small stature, rule out hearing loss, speech and language delays and global developmental delay, hypoplastic left testicle, incoordinated swallowing, rule out genetic syndrome related to hypoplastic facial features, developmental delay, small stature and familial resemblance.

In the pediatric genetics dysmorphology clinic, the above dysmorphic features were confirmed. He also had distinctive blepharophimosis, ptosis, epicanthal folds, altered palmar creases and hyperextensibility of the fingers and knees. Ohdo blepharophimosis syndrome was diagnosed, based on a London Dysmorphology Database search. Chromosomal status was 46,XY.

At 17 months' chronologic age, his developmental quotient was 61, with most delay occurring in speech, which was at the five-month level. Motor skills were at the 11- to 12-month level. He was evaluated by subspecialists who addressed his various problems. Initial hearing assessment revealed moderate hearing loss. The child was referred to an early intervention program.

Subsequent follow-up at 52 months of age revealed that the boy still had difficulty with feedings and was not yet toilet trained. His cognitive skills were at approximately a 27-month level, and genetic follow-up confirmed Ohdo blepharophimosis syndrome. The mother had subsequently given birth to a second child with the same syndrome.

The physician must have a high index of suspicion to consider the diagnosis of mental retardation in any child. Some helpful clues include delayed speech, dysmorphic features (minor anomalies), hypotonia generally or of the extremities, general inability to do things for self and, not least, expressed concern by the parents.

The first and most important step in the diagnosis of mental retardation is to obtain a comprehensive patient and family history. Previous gynecologic and obstetric history may reveal infertility or fetal loss. Assessment of maternal health status during pregnancy with the involved child should include questions regarding use of tobacco, alcohol and drugs (prescribed and illicit); lifestyle or other risks for sexually transmitted diseases; weight gain or loss; signs of infection; serious illness or injury; and surgery or hospitalization.

To establish a knowledgeable baseline history of the child, the physician should obtain information regarding length of pregnancy, premature onset of labor or rupture of the membranes, duration and course of labor, type of delivery and any complications. Apgar scores at one and (especially) five minutes should be reviewed, and birth weight, length and head circumference measurements obtained and plotted on appropriate growth charts. The parents should be asked about any illnesses, feeding or sleeping difficulties in the newborn period and problems with sucking or swallowing, as well as the baby's general disposition. Extremes in infant temperament are often the first clue to an atypical course in child development.

The systems review of the child should be complete, with special attention to growth problems, history of seizures, lethargy and episodic vomiting. A developmental screen should be used at all well-child visits to obtain information about the timing of the child's developmental milestones, any concerns by parents or caregivers and comparison of the child's developmental rate and pattern with those of siblings. Specific questions about the child's current developmental abilities should be asked at each visit.

The Revised Denver Prescreening Developmental Questionnaire 10 is a useful screening tool that parents can readily complete to help determine the need for further evaluation with the time-honored Denver Developmental Screening Test. 11 , 12 Another practical and reliable tool with which to monitor development in infants is the Kansas Infant Development Screen. 13 The findings can be recorded and plotted just as with somatic growth charts and shared with parents. Other developmental screening tests are also available.

Delays in speech development are common and may become more obvious when contrasted with the speech development of a sibling. Inquiry should be made regarding concerns about hearing and vision. One cannot overemphasize the importance of addressing concerns voiced by a parent about a child's development, behavior and learning, because these expressed concerns accurately target the majority of children with developmental problems.

Information should be obtained about the family unit, parents' occupations and educational achievements, educational and developmental status of siblings, role of the patient in the family, discipline of the children and identity of the child's caregiver when the parents are not home. Family history of fetal loss, mental retardation, severe learning problems, congenital abnormalities and unexplained childhood deaths, as well as other serious illnesses in first- and second-degree family members, should be elicited.

A complete physical examination can begin with a review of growth curves since birth, if these are available. The head circumference should continue to be plotted. The examination should be thorough, with special attention to physical findings that are compatible with any risk factors obtained from the history.

The child should be examined closely for dysmorphic features or minor abnormalities, such as unusual eyebrow pattern, eyes that are widely or closely spaced, low-set ears or abnormal palmar crease patterns. Minor abnormalities are defined as defects that have unusual morphologic features without serious medical implications or untoward cosmetic appearance. 8 Most minor abnormalities involve the face, ears, hands or feet, and are readily recognized even on cursory examination. 14 The presence of three or more minor abnormalities in newborns is correlated with a 90 percent frequency of coexistent major abnormalities, 15 suggesting close association with morphogenesis in utero. Thus, minor abnormalities may provide clues to developmental problems of possible prenatal origin.

Evaluation of the head, face, eyes, ears and mouth must include general assessment of visual acuity and hearing. Examination of the chest, heart, spine, abdomen, genitalia, extremities, muscles and neurologic reflexes can reveal abnormalities that may be associated with retardation. Table 2 highlights five common syndromes or problems associated with retardation.

Evaluation and Referrals

Findings from the history and physical examination of the child will help determine which diagnostic tests and referrals are appropriate for further assessment. The physician needs to explain to the parents what these findings are and the reasons for further evaluation. The laboratory and radiographic assessment of individual children should be based on clinical presentation ( Table 3 ) . 16

This initial sharing of information with parents is an extremely important step and will probably set the stage for the future physician-family-patient relationship. Ample time should be scheduled to discuss the findings and to allow for questions, which will be numerous. The family should be encouraged to write a list of questions for further communication with the physician. The clinician should clarify the term “developmental delay,” because parents frequently misinterpret this as meaning the child has the ability to catch up.

It is best to seek other opinions as soon as mental retardation is suspected rather than adopting a “wait-and-see” approach. The Individuals with Disabilities Education Act (1997) 17 provides for developmental assessment of children older than three years in every school district. For children younger than three, similar infant-toddler assessment and early intervention resources are available, usually through local health departments, school districts or regional assessment centers. (The responsible agency varies in each state.)

Referral may be made to a tertiary-level child development unit that can provide interdisciplinary evaluations (developmental pediatrics, genetics, neurology, ophthalmology) as well as functional assessments (occupational and physical therapy, speech/language pathology, audiology, psychology). Families will usually welcome such a referral and comprehensive evaluation, especially if the mental retardation is unexplained. Evaluations by a nutritionist and a child psychiatrist may also be appropriate for some patients.

The family physician should expect complete information on the findings from this type of team evaluation. The family should expect to be referred back to their local community for ongoing primary care and, in some instances, subspecialty care. Information about early intervention resources in the local community should be shared with the family, and appropriate support services should be identified.

If the child with mental retardation has a head circumference that falls below the 5th percentile (microcephaly) or above the 95th percentile (macrocephaly), a magnetic resonance imaging scan of the brain should be considered. This is usually preferable to computed tomographic scanning because of the enhanced visualization of developmental abnormalities of the cerebral cortex, such as pachygyria, polymicrogyria and schizencephaly. These disorders reflect an abnormality during the first 25 weeks of gestation in the early migration of the neurons into the normally six-layered cortex.

A consultation with a medical geneticist/dysmorphologist is invaluable. This would include a review of a three-generation pedigree and records of pertinent relatives, evaluation for subtle dysmorphic features and assessment for a pattern to the patient's presenting characteristics.

Most mentally retarded patients who visit a genetics office undergo chromosome analysis. While this testing could be done by the referring physician, there are different levels of test quality, and it is usually best performed by a good cytogenetics laboratory associated with a university hospital or children's hospital. This allows for ease in interpretation of the results to the patient's family in the event an abnormality is found. DNA testing for fragile X syndrome should be done instead of cytogenetic testing, which can miss up to 7 percent of those who are affected. 18 Metabolic testing in the absence of a history suggestive of metabolic disease is probably of little value. 4

Diagnosis may require several periodic visits to a geneticist, because a phenotype may evolve slowly, and new syndromes are constantly being reported. The importance of making a diagnosis in a child with mental retardation cannot be overemphasized. An accurate diagnosis allows for anticipatory guidance for the patient, recurrence risk information and genetic counseling for the parents, and opportunities for the family to become involved in specific support groups. An uncertain diagnosis should be conveyed as such; no diagnosis is preferable to an incorrect one.

Within a given family, the risk of recurrence of mental retardation in future siblings or other relatives of the patient depends on the specific diagnosis. The recurrence risk for mental retardation cannot be given to the family until a diagnosis has been made, although a general discussion with a geneticist may be of benefit. The family physician is a valuable resource in periodically reviewing the recurrence risk for the family.

Practice guidelines for primary care of children with certain conditions (Down syndrome, fragile X syndrome) are also available, 19 – 21 as are special somatic growth charts for some syndromes. There are also guidelines for the management of adults with mental retardation who have been deinstitutionalized. 22 Table 4 lists Internet resources that may be valuable to the family physician.

All physicians who care for children with mental retardation or developmental disabilities should remember that these patients quickly outgrow their childhoods. As they become adolescents and young adults, most of them will need professional intervention to help them become their own advocates in the health care system. Families should be supported as they encourage independent functioning on the part of their adolescent or young-adult son or daughter. 23 Issues relating to sexuality, family planning, custodial care, estate planning and guardianship are highly important but are beyond the scope of this article.

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Case 28 Teaching Students With Mental Retardation

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Charity is a 13-year-old Native American girl who attends Black Hills Middle School. Charity has Down syndrome concomitant with mild mental retardation. She has been included in GPE since kindergarten and participates in regular physical activities. Some students in this GPE class exhibit positive attitudes and behaviors toward Charity. One Monday, Charity does not participate with her peers in any of the station work outside on the blacktop. Instead, for the entire class, Charity sits singing on some benches adjacent to the playing area. Fortunately, this is not always the case. Volleyball is a favorite of Charity's and she really seems to enjoy playing. Throughout the games, she is verbally interactive with her classmates. At home that evening, Charity tells her mother about the boys in PE. Mrs. Keller, Charity's mother, learns that Charity really enjoys GPE and has developed several friendships in her classes, but feels uncomfortable with some of the boys in the class.

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Siblings' experiences of having a brother or sister with autism and mental retardation: a case study of 14 siblings from five families

Affiliation.

• 1 Department of Health Sciences, Section of Nursing, Lund University, Lund, Sweden. [email protected]
• PMID: 17889735
• DOI: 10.1016/j.pedn.2007.08.013

The aim of this study was to describe the present and past experiences of 14 siblings from five families in terms of having a brother or sister with autism and mental retardation. Personal interviews were conducted with the siblings before their brothers or sisters were moved to a newly opened group home. Qualitative content analysis was used for the analysis of the transcribed texts. The analysis resulted in seven content categories: precocious responsibility, feeling sorry, exposed to frightening behavior, empathetic feelings, hoping that a group home will be a relief, physical violence made siblings feel unsafe and anxious, and relations with friends were affected negatively. The conclusion is that these siblings' experiences revealed stressful life conditions. Counseling for the family and for siblings is recommended to help them deal with their feelings and problems. For the siblings in these five families, a group home was a relevant alternative as a temporary or permanent placement for the child with autism and mental retardation.

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Essay Service Examples Health Mental Retardation

Case Study of Mental Retardation in Patients

• Father’s name: M. R
• Gender: Female
• Religion: Islam
• Address: Faisalabad
• Birth order: 1st
• Siblings: 4(2 brothers, 1 sister)
• Marital Status: Unmarried
• Education: 2nd Year
• Father Alive/Dead: Alive
• Mother Alive/Dead: Alive

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• Father’s name: M.R
• Gender: Male
• Birth order: 5th
• Siblings: 7(4 brothers, 2 sisters)
• Education: MPhil
• Father Alive/Dead: Dead
• Father’s name: M.I
• Birth order: 2th
• Siblings: 2(2brothers, 0 sisters)
• Education: 5th class
• Social economic status; middle
• Father Alive/Dead: alive

Recommendations:

• Social and cognitive therapy
• Behavioral therapy
• Speech therapy

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