Mentally Challenged Child: How To Deal With Them?

Mental retardation people have low intelligence and poor development skills, and the child will delay today’s required activity.

The child may learn slowly or have learning difficulties. Mental handicaps.

Mental Retardation children include children with: 

  • Mental retardation
  • Cerebral Palsy  
  • Down syndrome Mental retardation
how to teach mentally challenged child
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Table of Contents

Mental retardation

 Definition

Mental retardation is a sub-average in general intellectual functioning associated with significant impairment in adaptive behavior (including thinking, learning, social and occupational adjustments), which manifests during the developmental period (before 18 years of age). 

Measurement of IQ 

Mental retardation level 

  • Mild -70-50 
  • Moderate -50-35  
  • Severe -35-20 
  • Profound – Below 20 

Intelligence Quotient(IQ)

  • = (Mental Age/Chronological Age) x 100

Classification of Mental Retardation

Mild mental retardation

  • This is the most typical kind of mental retardation, accounting for 85-90% of cases. Children with IQ 51-70 fall in this category.
  • During infancy, mild mental retardation often remains unnoticed. During late infancy and early childhood, the caregiver may note the developmental delay in language, social development, and motor skills. During primary school, these children may find the problem in reading and arithmetic. 
  • This group is referred to as ‘educable.’ In adulthood, mild, mentally disabled people may live independently.

Moderate mental retardation

  • About 10% of mentally retarded have mild mental retardation. IQ is between 36-50.
  • Moderately mentally disabled children display delays in motor development and speech. They have to train to support themselves by performing semiskilled or unskilled work under supervision. 
  • This group is referred to as ‘trainable”. During adulthood, these people can work in supervised occupational settings

Severe mental retardation

  • About 4% of mentally disabled children fall into this category. Their IQ is between 21-35.
  • Severe mental retardation is seen in early life due to low motor development and the absence of speech and communication skills.

Profound mental retardation

  • This group accounts for 1-2% of all mentally retarded. Their IQ is below 20. 
  • Physical defects associated with mental retardation are seen in these children. The achievement of developmental milestones is a delay. 
  • These children often need complete nursing care or ‘life support’ under a carefully planned and structured environment like group homes.
  • Disorders frequently found in mentally disabled children are:

Problems/Disorders Associated with Mental Retardation

Motor defects

  • Spasticity
  • Ataxia (lack of coordination in doing voluntary activities)
  • Athetosis (Slow, purposeless and involuntary movements of hands, face, feet, and tongue)
  • Epilepsy (seen in severely mentally disabled children)

Physical defects

  • Sensory disorder (found in 20% cases)
  • Defect in vision
  • Defect in hearing

Psychiatric disorders

Causes of Mental Retardation

Antenatal Causes

  • Deficiency of folic acid in mother
  • Viral infections to mothers during the first trimester of pregnancy (such as Pertussis, mumps, rubella, syphilis, etc.)
  • Exposure of pregnant female to radiations 
  • Consumption of drugs, chemicals, or intoxicants by mother like lead, thalidomide, etc.
  • Placental dysfunction leading to hypoxia and growth retardation
  • Endocrine disorders like Hypothyroidism 

Intra Natal Causes

  • Birth asphyxia
  • Prolonged or difficult labor 
  • Prematurity
  • Instrumental delivery
  • Birth injuries (head injury, intraventricular hemorrhage)

Postnatal causes

  • Cranial Injury (Accident and child abuse)
  • Infections like meningitis and encephalitis
  • Intoxication (lead)
  • Kernicterus 

Genetic causes

  • Chromosomal anomalies like Down syndrome, Klinefelter’s syndrome, Fragile x-syndrome, Trisomy X, Turner’s syndrome. 

Metabolic disorders

  • Disorders of protein metabolism like Phenylketonuria.
  • Disorders of fat metabolism like Gaucher’s disease.
  • Disorders of carbohydrate metabolism like Galactosemia.
  • Disorder of urea cycle like Amino succinic aciduria.
  • Miscellaneous disorders like Wilson’s disease

Diseases of brain

  • Tuberous sclerosis
  • Epilepsy
  • Neurofibromatosis

Cranial malformations

  • Microcephaly
  • Anencephaly
  • Hydrocephaly 

Psychiatric disorders

Diagnostic Evaluation 

        Mental retardation is a base on the following:

  • Thorough physical examination and history.
  • Routine developmental assessment 
  • Standardize tests of intellectual and adaptive functioning. Commonly used tests are the Denver Developmental Screening Test Il, Stanford Binet Intelligence Scale, Wechsler intelligence scale, etc. 
  • A child whose IQ is found in below 70 on the Stanford Binet test is classified as “Mentally retarded

Management

  • There is no standard medical treatment for mental retardation; however, prevention is the best approach. Prevention can do done at three levels:

            Primary Prevention

  • It consists of planned actions taken to reduce the incidence of mental retardation. It involves health promotion strategies and specific protection (identification of risk factors and then removing them).

Health Promotion

It includes:

  • Good antenatal care
  • Improving the socio-economic status of the country
  • Educating people
  • Family and genetic counseling
  • Facilitating research to identify cause and risk factors of mental retardation.

Specific Protection

  • It includes:
  • Good prenatal, intranasal, and postnatal care.
  • Genetic counseling of high-risk mothers.
  • Avoiding childbirth in late maternal age.
  • Avoiding consanguineous marriages.
  • Avoiding marriages of mentally retarded
  • Medical measures for preventing maternal infections during pregnancy (like rubella, syphilis, and toxoplasmosis), toxemia of pregnancy, trauma, malnutrition, obstetric complications, smoking, alcoholism, etc., adverse effects on fetal development.
  • Prematurity and neonatal medical conditions (like kernicterus) should promptly manage. 

Secondary Prevention

  • It involves early diagnosis and case finding, followed by interventions to limit the disability.
  • Early detection and treatment
  • It includes early detection and treatment of preventable disorders, which may lead to mental retardation like Phenylketonuria, Hypothyroidism, etc. 
  • Early detection and treatment of sensory, motor, and behavioral handicaps.
  • Early recognition that indicates the presence of mental retardation. A delay in diagnosis leads to rehabilitation.

Tertiary Prevention

  • Tertiary prevention aims to limit disability and promote repair.
  • Disability limitation
  • It includes

Institutional care of severe or profound mentally retarded

  • Education in special schools, if educable.
  • Vocational training, if trainable.
  • Regular physiotherapy to treat associated defects.
  • Education in special schools, if educable.
  • Vocational training, if trainable.
  • Regular physiotherapy to treat related defects.
  • Rehabilitation 
  • Rehabilitation in vocational, physical, and social areas is the cornerstone of the management of mentally disabled children. It depends on the patient’s intelligence level and his capacities.

Care of Hospitalized Mentally Retarded Children

  • mentally disabled children need hospitalization in the following conditions:
  • Behavioral difficulties due to attention deficit hyperactivity disorder, destructive or assaultive behavior, psychosis, or organic psychosis.
  • Social factors like incompetent parents, single parent, overcrowded houses, no one to take care of the child, etc 

Counseling of Parents

  • The parents of mentally disabled children require perseverance and patience, as they have to make long life adjustments. 
  • Counseling parents helps them in taking proper care of the child. 
  • It helps the parents to understand and accept the child’s problems and plan his care accordingly.
  • Counseling should focus on:
  • ü Providing complete information about mental retardation.
  • ü Developing the right attitude of parents towards the disabled child.
  • They are educating the parents about their role in the training of the child.
  • ü Providing professional help for treating associated conditions or complications like seizures, hyperactivity, psychosis, etc.
  • ü Providing information regarding facilities available in the society for such disabled children like NGOs running daycare centers, shelter homes, special schools, etc. 

Cerebral palsy

Definition

  • Cerebral Palsy is a chronic non-progressive motor dysfunction caused by damage to the brain’s motor areas. (Blosser and Burns, 2004)
  • The word ‘cerebral’ refers to the cerebrum, which is the affected area of the brain, and ‘palsy’ refers to a movement disorder.

To learn more, you can read: How To Prevent Bell’s Palsy?

Causes

  • Cerebral Palsy damages the developing brain’s motor control centers, which can occur during any abnormality in pregnancy, childbirth, or the age of three years.
  • This results in activity limitation accompanied by:
  • Disturbances or sensation
  • Depth perception 
  • Sight based problems
  • Communication impairments 
  • Cognitive impairment. 

Factors contributing to cerebral palsy

Prenatal factors

  • Genetic or chromosomal anomalies
  • Brain malformations
  • Exposure to teratogens
  • Multiple fetuses  
  • Intrauterine infections
  • Placental problems are causing insufficient nutrition and oxygen delivery to the fetus.

Birth factors 

  • Preeclampsia
  • Complicated labor and delivery
  • Birth injury caused by direct head trauma
  • Asphyxia secondary to cord prolapse or strangulation

Perinatal Factors 

  • Central Nervous system infection
  • Kernicterus 

Childhood factors

  • Head trauma
  • Meningitis
  • Toxic ingestion like lead poisoning
  • Shaken Baby Syndrome
  • Incidents are causing Hypoxia to the brain like near drowning, choking due to foreign body aspiration, and poisoning.

Classification/Types of cerebral Palsy

  • Cerebral palsy is divided into four major classes according to different impairments and areas of the brain that are damaged. 

Types of Cerebral Palsy: 

  1. Athetoid/Dyskinetic
  2. Spastic Cerebral Palsy
  3. Ataxic cerebral palsy
  4. Mixed type 
Athetoid/Dyskinetic 
  • Athetoid cerebral palsy require mixed muscle tone-both hypertonia and hypotonia.
  • Patients have trouble sitting and walking.
  • Difficulty in maintaining objects, tiny ones, requires fine motor control like toothbrush or pencil.
  • 10% of patients have this cerebral palsy.
Ataxic cerebral palsy
  • Caused by damage to the cerebellum.
  • Occurs in about 10% of cases.
  • Hypotonia and tremors may be present.
  • Wide based gait.
Spastic cerebral Palsy
  • This is the standard type of cerebral palsy occurring in 80% of all cases. 
  • These patients have hypertonia and neuromuscular mobility impairment due to upper motor neuron lesions in the brain and corticospinal tract or motor cortex.
Spastic Hemiplegia
  • In this type, only one side of the body is affected by hemiplegia.
  • Injury to the right side of the brain can cause the left side body deficit and vice versa.
  • These patients are most ambulatory of all forms of spastic cerebral palsy.
  • The affected persons have equinus (limping instability) on the dramatic side and are prescribe ankle-foot orthosis to prevent equines
Spastic Diplegia 
  • In this type, lower extremities are affected with little or no upper body spasticity. 
  • These patients have a ‘scissors gait”.
  • based on gait analysis, patients are provided with walkers, crutches, or canes to help them in movement. These patients may also have nearsightedness or strabismus.

Mixed type

  • Symptoms of more than one form exist in these patients.

Clinical Features

  • Abnormal muscle tone, motor development reflexes, and coordination problems.
  • joint issues such as collective spasm and muscle spasm
  • floppy or very stiff body
  • seizures
  • delay in language development
  • hearing impairment
  • abnormal posture
  • stiff joints
  • learning difficulties
  • mental retardation
  • urinary incontinence
  • pain associated with spasm of muscles.

Diagnostic Evaluation

  • Patient’s history
  • Physical examination
  • CT or MRI to treat the conditions such as hydrocephalus, arteriovenous malformation, and subdural hematomas. 

Management

  • Treatment
  • Physical therapy
  • Occupational therapy
  • Speech therapy
  • Biofeedback
  • Massage therapy
  • Drug therapy
  • Surgery and Orthosis

Physical therapy

  • Physiotherapy programs are designed to improve gait and voluntary movements, together with stretching programs to limit contractures. 
  • Life-long physiotherapy is essential for muscle tone and prevents dislocation of joints.

Occupational therapy

  • It helps adults and children maximize their functioning, adapt to their limitations, and live independently as possible. 
  • it helps in participating in activities of daily livings that are meaningful to them.
  • it helps to activities of daily living that are meaningful to them. 
  • Occupational therapists may address sensory, cognitive, or motor impairments resulting from cerebral palsy.
  • The Occupational therapist typically facilitates identifying the child’s abilities and difficulties and environmental conditions, such as physical and cultural influences, that affect his participation in daily activities. 

Speech therapy

  • It helps control the muscles of the mouth and jaw and helps improve communication. 
  • Speech therapy should continue throughout the school years.

Biofeedback

  • It is an alternative therapy in which people with cerebral palsy learn to control muscle spasms.

Massage therapy

  • It is designed to help relax tense muscles, strengthen muscles, and keep joints flexible.

Drug Therapy

  • Botulinum Toxin A injections are using as a treatment of spasm and dystonia.

Surgery and Orthosis

  • Commonly, it is performed on the hips, knees, hamstrings, and ankles, most often performed on the hips, knees, hamstrings, and ankles for loosening of tight muscles and releasing fixed joints.
  • Straightening bizarre twists of the leg bones, i.e., femur and tibia. 
  • Cutting nerves of the limbs most affected by spasms. This procedure, called rhizotomy (‘rhizo,’ meaning root and tomy meaning a cutting off), reduces the spasms.
  • Orthotic devices such as ankle-foot orthosis are often prescribed to minimize gait irregularities and increase speed.

Down syndrome

we all humans have 23 pairs of chromosomes in each cell of the body. The presence of extragenetic material in chromosome 21 leads to Down syndrome. The estimated incidence of Down syndrome is 1 in 1000 live births. The incidence of Down syndrome increases with advancing maternal age.

Clinical features 

These babies have typical facial features like upslanting eyes and flat facial profiles referred to as Down facies or mongoloid facies, large space between the big toe and next toe (sandal gap) a large tongue.

Hearing impairment (60-80%), congenital heart defects (40-50%), and low thyroid hormone levels (Hypothyroidism) are commonly associated. 

There is often a delay in attaining motor milestones, and limbs feel soft and floppy (hypotonia) 

it increased the risk for seizures, recurrent chest infection, immunological disorders, blood cancers (leukemia), and skin problems. 

Diagnosis

Diagnosis is suspected on clinical features and confirmed by analyzing the number of chromosomes by karyotyping. These children should screen for hearing (auditory brainstem evoked response), blood levels of thyroid hormone, echocardiography to look for any associated congenital heart defects.

Prevention

If the parents already have one child with Down syndrome, the recurrence risk in the next pregnancy will depend on the parents’ karyotype and the mother’s age. 

Antenatal screening use for antenatal diagnosis of Down syndrome comprises alpha-fetoprotein (AFP), nuchal translucency screening (NT) by ultrasonography, and tissue diagnosis by amniocentesis or chorionic villus sampling (CVS). Parents should consult a geneticist regarding the same.

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