Mentally Challenged Child: How To Deal With Them?

 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

• Schizophrenia
• Neurosis
• Mood disorders
• Personality disorders 
• Organic psychiatric diseases like dementia
• Autism and overactivity syndrome
• Behavior disorders like mannerism, headbanging, and hyperkinetic syndrome.

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

• Autism
• Childhood-onset schizophrenia
• Asperger’s syndrome 

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.