1. MENTAL RETARDATION Presenter : Dr. Santanu Ghosh, Post Graduate Student. Moderator : Dr. J. N. Das Assistant Professor. Assam Medical College & Hospital 1 Saturday, September 12, 2009

3. Historical review

4. What is mental retardation?

5. Epidemiology

6. Classification

7. Etiology

8. Clinical presentation

9. Comparative Nosology

10. Psychopathology

11. Clinical assessment

12. Management

13. Prevention

14. Miscellaneous issues

15. Conclusion

16. Bibliography2

17. Introduction: Mental retardation is one of the commonest diagnosis in children attending various psychiatric settings in India as well as other developing countries, forming 30-50% of the attendance in the pediatric age group. It is a multidimensional problem. The dimension include- psychological, medical, educational & social aspects, with the social aspects being most important. 3

18. HISTORICAL REVIEW: Felix Platter (1536-1614): First described "mental alienation" including both mental retardation and mental illness. Association of Medical Officers of American Institution for Idiotic and Feebleminded Persons was established by Edouard Seguin in 1876 American Association of Mental retardation was established in 1919 The Arc ( the Association Retarded Citizens) was established in 1950 American Association on Intellectual and Developmental Disabilities was established in 2006 4

19. What is Mental Retardation? An individual is considered to have mental retardation based on the following criteria: Sub-average IQ (less than 70 ) Deficits in at least two areas of adaptive skills: communication, self-care, social skills, academics, leisure, health, and safety. Onset before the age of 18 5

20. General intellectual functioning: It is defined as the results obtained by the administration of standardized general intelligence tests developed for the purpose and adapted to the conditions of the region/ country. 6

22. IQ of approximately 70 or below.

24. Zone of uncertainty: IQ= 70 (66-74) 7

25. ADAPTIVE BEHAVIOUR: It is defined as the degree with which the individual meets the standards of personal independence & social responsibility expected of his age & cultural group. The expectation of adaptive behavior vary with the chronological age. 8

28. 11 Normal Milestone:

29. EPIDEMIOLOGY: Global Prevalence: 1-3% M:F = 11/2 : 1 India: Prevalence: 2% Mild MR = 20 million Moderate MR = 4 million Severe MR = 4 million Profound MR= 1-2% Severe MR = 3-4% Moderate MR = 10% Mild MR : 85% Highest incidence = 10-14 years 12

31. Psychological

32. Educational

33. Nosological13

35. Trauma & physical agent

36. Metabolic or nutrition

37. Gross brain disease

38. Chromosomal abnormality

39. Gestational disorder

40. Psychiatric disorder

41. Environmental influence

42. Other influences14

43. Classification cont… Psychological classification: 15

45. classification contd.. 17

46. Classification cont… 18 Nosological Classification:

47. Traditional terms related to Mental Retardation: IDIOT: The greatest degree of intellectual disability, where the mental age is two years or less, and the person cannot guard himself or herself against common physical dangers. The term was gradually replaced by the term profound mental retardation. 19

48. Traditional terms related to Mental Retardationcontd… IMBECILE: An intellectual disability less extreme than idiocy and not necessarily inherited. It is now usually subdivided into two categories, known as severe mental retardation and moderate mental retardation. 20

49. Traditional terms related to Mental Retardation contd…. Moron : Defined by the American Association for the Study of the Feeble minded in 1910, as the term for an adult with a mental age between eight and twelve; mild mental retardation is now the term for this condition. 21

50. Presentation of Mental Retardation: The symptoms and signs of MR include: Behavioral disturbances Language delay Fine-motor and gross motor delay Neurological and physical abnormalities visual and hearing impairments 22

52. Fragile X syndrome

53. Turner’s syndrome

55. Phenylketonuria

56. Homocystinuria

57. Hartnup’s diseases

58. Lipids:

59. Tay- Sachs disease

60. Gaucher’s disease

61. Niemann-Pick disease 23

63. Galactosemia

64. Glycogen storage disease.

65. Purines:

66. Lesh-Nyhan Syndrome.

67. Mucopolysaccharidosis:

68. Hurler’s disease

69. Hunter’s disease

71. Neurofibromatosis

74. Syphilis

75. Toxoplasmosis

76. CMV inclusion disease Prematurity Birth trauma Hypoxia IUGR Kernicterus Placental abnormalities Drug during 1st trimester. 25

78. Cretinism

79. Trauma

80. Lead poisoning

81. Cerebral palsy26

83. COMORBID PSYCHOPATHOLOGY IN MENTAL RETARDATION 28

85. Convulsion may vary in their frequency, duration & type depending upon the nature of brain damage.

86. Fits are more common in person with severe & profound mental retardation than in those with mild or moderate MR.29

88. Prevalence – 9-18% of MR.

89. Excessively active, distractible, having poor attention span, restlessness, lack of inhibition, poorly organized & poorly coordinated activity.

90. Impulsive, aggressive & fluctuation in their mood. 30 B)Attention Deficit Hyperkinetic Disorder(ADHD):

92. It increases with greater severity of cognitive . disability.

93. It takes form of chronic, repetitive & frequently .stereotyped behavior causing trauma.

94. It occurs in relation to specific genetic . . . . . syndromes: Lesch-Nyhan Syndrome. Smith- MagenisSundrome.

96. Prevalence: 1-25% of MR.

97. MR patients may not be able to identify the subjective anxiety. Aggression & agitation may be suggestive of anxiety disorder.32

99. As diagnosis of schizophrenia essentially requires that the patient relate the experience of delusion & hallucination- the diagnosis of classic schizophrenia is arguably impossible.

100. In such cases diagnosis should be made- Psychosis-NOS. 33

103. Oppositional Defiant Disorder or , , , , , Conduct Disorder:

104. Organic Mental Disorders.34

105. CONDITIONS MISDIAGNOSED AS MENTAL RETARDATION: Early infantile autism Child with hearing impairment Child with emotional disturbance Cultural deprivation & lack of stimulation Specific learning disabilities Childhood psychosis Child with visual handicap Child with physical handicap 35

106. Differences in Presentation in Mental Retardation from Autism: 36

107. Course & Prognosis: Outlook is good for many with mild MR or Cultural-familial Retardation. In non-academic settings they can function acceptably and are not considered retarded. Appropriate training and opportunities must be provided Severe and profound MR, Organic Retardation, is lifelong, and biologically based. Many people with MR are living longer; Down Syndrome patients live up to the mid-50s on average. Issue of their care in later years, when some decline cognitively due to gene damage in those with Down Syndrome 37

109. Treatment proper

110. Prevention 38

111. CLINICAL ASSESMENT 39

114. Psychological Assessment in Mental Retardation: Tests commonly used are: Developmental schedules- Bayley infant scale Gassell’s developmental schedule NIMH Developmental Assessment Schedule Verbal tests: Binet Kamat Test Binet Kulshresta Test Binet Shukla Test Malin’s Intelligence Scale for Indian Children 41

115. Psychological Assessment in Mental Retardation contd… Non-Verbal Tests: Developmental Screening Test Raven progressive matrices-cololured Performance tests: Seguin Form Board Test Gassell’s Drawing Test Draw- A- man Test Malin’s Intelligence Scale for Indian Children Alexander’s passalong Test Koch’s Block Design Test 42

116. 43 Psychological Assessment in Mental Retardation contd… Adaptive Behavioral Scale: Vineland Social Maturity Scale AAMR- Adaptive Behavioral scale Test for specific abilities: Attention- concentration Test Test of perception

117. IQ Tests for diagnosing MR: 44

119. Check whether the person comprehends the test instructions & has adequate speech, language for communication.

120. Use one standardized test battery which give general ability index & a few suitable sub-tests for individual abilities.

121. Use one standardized scale for adaptive behavior.45

123. Start with a simple test, preferably a non-verbal test to put the child initially at ease.

124. Keep the colorful, sturdy & useful toys suitable for different age levels. This will help in building the rapport.46

125. 47 Treatment Proper:

127. Availability of proper facilities for learning & developing social, academic, vocational & motor skills & later suitable job.

128. These provides a sense of self- dignity, identity & responsibility to the person, helping him to adjust in life & for adaptation.48

129. Management contd…. Management of accompanying Psychiatric disturbances: Skill training. Pharmacotherapy. Role of behavioral modification 49

130. Skill Training: Urban area: Special school, vocational training centers & child guidance clinic in general hospital Rural area: Village level worker is equipped with skills in the home training of mentally retarded persons. The level of performance of MR patient must be assessed in the following areas: Vision & hearing Gross motor & fine motor ability Self care ability Language ability Cognitive ability Social & emotional ability 50

132. Give the mentally retarded person repeated training in each activity.

133. Give the training regularly & systematically.

134. Do not let parents get impatient.51

136. MR patients are more sensitive to the side effects & toxicity of the drugs.

137. MR patients are responsive to lower doses of various psychotropic drugs.

138. Golden rule: START LOW, GO SLOW 52

140. There are 5 major steps in the implementation of behavior modification programme. These are -Identification of the problems. Defining target behaviors. Behavior recording(baseline & treatment) Functional analysis & Treatment procedures & their evaluation. 53

142. Sincerity, reassurance, effective communication & emotional stability are the important measures.

143. The stages of counseling

144. Imparting information regarding the condition of the mentally retarded child .

145. Helping the parent to develop right attitudes towards their handicapped child and

146. Creating awareness in the parent regarding their role in training their mentally retarded child.54

148. Introduction of new, pleasurable & useful skills, to increase child’s knowledge.

149. Frequent play therapy session.

150. Extra & special coaching in a small group to cover up for social & cultural deprivation.55

152. Vocational services includes: - Counseling of the trainers & their families - Supported employment including job . . . placement. - Multiple physical handicap: physical .rehabilitation- physiotherapy, orthopedic services. - Sensory handicap: Special training. 56

153. PREVENTION 57

154. Primary Prevention: AIM: Eliminating factors leading to MR or reducing its incidence. Preventable measures include: Public Education Improved Maternal & Child Care Genetic Counseling 58

155. B) Secondary Prevention: AIM: Early detection & intervention. Preventable measures include: Screening of inborn error of metabolism Screening of endocrine disorders e.g. Hypothyroidism Dietary restrictions- Galactosemia, Phenylketonuria & maple syrup urine disease 59

156. C) Tertiary Prevention: AIM: Minimize the complications or sequele resulting from mental retardation. Various measures include: Management of emotional & behavioral problems of mentally retarded patients. Parental counseling Rehabilitation for mentally retarded. Special education facilities for children 60

157. Miscellaneous issues: 61

159. Female patient in adolescence or early adulthood may need this because girls may subjected to sexual abuse resulting in unwanted pregnancy.

160. Due to legal aspects involved, individualized advice may be given depending upon severity of MR, social support & attitude of care taker. 62

162. A lack of capacity to understand the obligations of marriage & to give valid consent.

163. Mild MR cases who have attained a satisfactory degree of achievement in life & self dependence, not suffering from genetic defect a consideration for marriage may be given.63

165. Consultant to various special schools or various institute for mentally retarded.

166. Rehabilitation services.64

168. Mild Mental Retardation : 50%

169. Moderate Mental Retardation : 75%

170. Severe Mental Retardation : 90%

171. Profound Mental Retardation : 100%

172. According to National Institute for Mentally handicapped,Secunderabad: % of disability = 110 - IQ score 65

173. Conclusion: Mental retardation presents with global delays in cognitive & adaptive functioning. When considering this diagnosis, it is important for physicians to be familiar with age- appropriate developmental milestones, specially during the formative years. It is also important for physician to be mindful that ultimate functioning can vary significantly & be influenced by individual strengths, community & family support. Above all those who suffer from MR are also human being. So being a human being they should get same advantages like other normal persons for betterment of their condition. 66

175. www.wikipedia.com

176. www.aamr.org

177. www.nlm.nih.gov

178. www.thearc.org

179. www.googleimage.com67

180. THANK YOU YOUR SUBTOPICS GO HERE 68