1. INTELLECTUAL DISABILITIES MENTAL RETARDATION Martha K 8/May/2015

3. Definition. Its characterized by deficits in general mental abilities such as reasoning,problem solving,planning,abstract thinking,judgement, academic learning and learning from experience. Intellectual disability is a developmental problem manifested during a child’s years of development (0-18yrs) Intellectual disabilities are defined by three criteria; 1.Characterised by significantly below-average intellectual functioning usually measured as IQ. 2.Impairments in adaptive functioning generally (inability to master social and educational skills despite the chronological age). 3.Deficit should manifest before age 18 years not associated to any injury or illness in later life.

4. Conti.. Due to stigma the term Mental retardation as DSM IV TR is replaced by Intellectual disabilities because these individuals can learn a range of skills and abilities if proper education and opportunity is attained. UK and USA have greatly adopted the new term which describes disorders of intellectual functioning.

5. Severity There are three domains (Conceptual, social and practical)and four severity levels: Mild: Preschool there is no obvious impairment /in school age children show learning deficits/Compared to peers are immature and practically act appropriate to self care. Moderate: Lag behind/Gap between them and peers/Care for personal needs. Severe: Attainment of skills is limited/spoken language and grammar plus vocabulary are limited to single words and phrases/Support required. Profound: Physical world interpretation lags too far behind/have very limited understanding of speech and gestures/depend on others for safety, care, health and more.

6. Criteria for Intellectual Disability. There are two types, namely: 1.The Traditional criteria for Intellectual disabilities (DSM IV TR).  Represented in DSM IV TR IN Axis II disorder mental retardation.  Diagnostic feature is significantly below average intellectual functioning as measured by IQ score of less than 70% and should be culture sensitive,- Criterion A  Evidence of significant impairments in adaptive functioning (communication, self care, home living, social or interpersonal skills leisure etc)-Criterion B.  Onset should have occurred before age 18 years during dev’tal periods of intellectual and adaptative functioning. Criterion C

7. Conti.. Teachers and medical doctors are a source of information to confirm. DSM IV TR divides the disability into levels of severity based on the IQ range presented by the sufferer. These are; Mild mental retardation-DSM IV TR Definition represented by IQ between 50-55 and 70. Includes about 85% (Usually acquire good social and communication skills which are trainable in adulthood for minimum self support. Moderate mental retardation-35-40 and 50-55. 10% (Can carry on simple conversations and with support and supervision benefit from vocational training. Severe mental retardation-20-25 and 35-40. Represents 3-4% ( Unable to acquire early communication speech but after school age can acquire some speech and self-care skills) Require supervision but can acquire basic vocational skills in sheltered work settings. Profound mental retardation-20-25, 1-2% ( Most have a neurological condition that causes the disability with considerable impairment in sensory-motor functioning. May respond to simple demands but have no other verbal abilities. Usually institutionalized due to the severe behaviour problems as well as concurrent physical handicaps.

8. Conti.. 2. Recent alternative approach to defining Disabilities (Focus on individual’s needs and abilities identify factors that are essential for facilitate intellectual and adaptive functioning rather than their deficits, impairments and limitations. People with disabilities differ severely in their with some able to function without notice in every day life while others may require constant supervision or sheltered environments. The same disabled people differ in personality, some may be passive, placid and dependent while others are aggressibve and impulsive. Hence differ in level of functioning as well as level of adaptive functioning.

9. Conti.. The American Association on Intellectual and Developmental Disabilities (AAIDD) has promoted an individualised assessment of a person’s skills and needs rather than the DSM IV TR criteria. This approach emphasizes both strengths and limitations in the individual which limitations need to be described in a way that enables suitable support to develop rather than chunking individuals into a DSM criteria. It evaluates the specific needs and suggests strategies, services and support-by parents, psychologists teachers, friends, GPs etc(resources and individual strategies necessary to promote development, education, interests and personal well being of the disabled) that will optimize individual functioning. They face stigma and prejudice which barriers realization of their potential.

10. Cont.. In UK, the special Education Needs and Disability Act result of such changes in attitude, s of 2001 rights were extended to be educated in mainstream schools. Where schools draw up Accessibility strategies-programmes that extend the rights of disabled to be educated in mainstream schools to make reasoning judgement so that they are not disadvantaged. As aresult of such changes in attitude, support and legislation- More than ½ of those with disabilities live with their parents or carers.

11. Prevalence/Epidemiology Mental retardation of a diagnosis at I % UK study showing IQ scores of less than 70 suggests between 5 and 10% in school children between 13-15 years 15% of the 70 IQ score were unrecognized to receive special educational needs. Epidemiology studies in UK show 580,000 people with mild intellectual disabilities with a prevalence of 0.95% and 217,000 with severe intellectual disabilities and a prevalence of 0.35%.(Open Society Institute, 2005) Unknown number is a possibility.

12. HISTORY. It was thought of as a spiritual attack and with mental retardation have been exalted, considered children of the Good God. To this day, movies such as “Being There” and “Forrest Gump” convey the message that persons with mental retardation are somehow blessed with simpler, more straightforward understandings of basic human truths. Yet, at the same time, such persons have also been neglected or deprived. Recognition and treatment of mental retardation dates to writings of Hippocrates, for example, described microcephaly and craniostenosis, and Galen actively explored causes of cognitive disability. In the Middle Ages, Avicenna proposed treatments for meningitis and hydrocephalus and even defined levels of intellectual function.

13. Conti… The modern history started in the late 18th and early 19th centuries. At that time, Jean-Marc Itard judged his work with Victor to be a failure, this renowned experiment marked the first time that anyone had considered the possibility that persons with disabilities could be educated. Itard's efforts sparked interest in educational and other interventions for persons with disabilities.

14. Aetiology of Intellectual Disabilities. These are hard to isolate and identify in individuals such that even when the cause is established say chromosomal disorder the two individuals may present with different levels of the disability. 1.Biological (major- with over 1,000 forms of impairment based on genetic, chromosomal or metabolic abnormalities) 2.Environmental factors (mild and moderate intellectual disabilities common in lower SES groups hence poverty and associated deprivation may retard intellectual development)Teenage mothers use alcohol, give provide poor nutrition hence increasing the likelihood of the disorder.

15. Developmental period and Risk factors 1.Before/During Conception Inherited recessive gene disorder (Phenylketonuria,Tay-Sachs disease) and Chromosomal abnormalities (Down syndrome, Fragile X syndrome) 2. During pregnancy Severe maternal deprivation, as a result of hormonal imbalance thyroxine deficiency maternal iodine deficiency-cretinism a congenital disorder resulting in slow de’t, ID and small stature, maternal infections (such as HIV,rubella, syphilis,herpes simplex), maternal drug abuse and maternal medications such as cancer chemotherapy. 3.During Birth Anoxia and hypoxia (oxgygen starvation) and low birth weight. 4.Early Childhood Brain infections (encephalitis, meningitis), childhood malnutrition, severe head injury (physical accidents, physical abuse such as shaken baby syndrome), exposure to toxins such as lead and mercury, and social deprivation and poverty (poor parenting, unstimulating infant environment)

16. BIOLOGICAL CAUSES. These are the largest known causes and are divided into three categories; 1.Chromosomal disorders 2.Metabolic disorders 3.Perinatal causes

17. Chromosomal Disorder  Genetically linked to abnormalities in the X chromosome which also determines biological sex. These include: Down syndrome and Fragile X syndrome  The abnormalities manifest as physical weaknesses in the chromosomes(irregular cell division during pregnancy)  Prevalence is 5% of all pregnancies which may cause miscarriage. And estimates show 0.5% of newborn babies have this disorder and may die soon after birth.Total is 25-30% of all intellectual disabilities.

18. Chromosomal disorder conti.. a)Down syndrome:  This disorder is caused by the presence of an extra chromosome in pair 21 and characterized by intellectual disability and distinguishing physical features.  First described by British doctor Langdon Down in 1866.  In 1959 French geneticist Jerome Lejeune first reported individuals with this syndrome.  Prevalence;0.15% of 1,000 births with risk being age of the mother.(women aged 20-24 risk is 0.07% and 40yrs is 1% and 4% for those at 45yrs) How is maternal age is linked to chromosonal abnormalities is still unclear?????

19. Cont… Moderate to severe is common and IQ between 35 and 55. Physical appearance includes; slant upward and outward with an extra fold of the skin that appears to exaggerate the slant, Usually shorter and stockier than average with broad hands and shorter fingers. They suffer physical disability such as heart problems, and appear to age rapidly with a mortality higher after age 40 close to signs of dementia (Alzheimer’s disease). Using Amninocentesis (extracting and analysing the pregnant mother’s amniotic fluid) procedure it can be identified prenatally in high risk parents done after week 15.15-30% identified of the tests in UK and USA.

20. b) Fragile X syndrome:  It’s a chromosomal disability that causes intellectual disability where the X chromosome appears to show physical weaknesses and may be bent or broken.  Occurs in approximately 0.08-0.04% of births  Mild to moderate levels of intellectual disability.  Language impairments  Behavioural problems (mood irregularities)  Physical characteristics include;(elongated faces and large prominent ears)  Different individuals may present differently such as some may have normal IQ but suffer specific learning disabilities, others may have emotional issues and characteristics of Autism such as hand biting, limited speech and poor eye contact.  Greater impairment in males because of the one X (XY) chromesome compared to females who have XX.

21. Metabolic Disorders.  These occur when the body’s ability to produce or break down chemicals is impaired.  There are many different types of metabolic disorders which lead to intellectual disability as a result of genetic factors carried by a recessive gene-A gene that must be present on both chromosomes in a pair to show outward signs of a certain x-tic.When both parents possess the defective recessive gene, the offspring is at risk of developing this disorder.  The include: a)Phenylketonuria (PKU) b)Tay-Sachs Syndrome.

22. Phenylketonuria (PKU).  It’s a metabolic disorder caused by a deficiency of the liver enzyme phenylalanine 4-hydroxylase, which is required for the effective metabolism of the amino acid phenylalanine.  As a result of this deficit, phenylalanine and its derivative phenylpyruvic acid build up in the body which damages the brain and CNS by preventing effective myelination-(Development of a protective sheath around the axons of neurons that allows effective transmission between nerve cells) of neurons  Results are severe mental retardation and hyperactivity.  In UK incidence is 1/10,000 live births, 1/70 people carriers  Routine tests for at risk parents and diet to foetuses and off springs at risk (special diet low in phenylalanine from birth -6yrs to minimize the neurological damage and intellect deficits.

23. Tay-Sachs Disease. Rare  It’s a metabolic disorder caused by a recessive gene which results in an absence of the enzyme hexosominidase A in the brain and CNS, eventually causing neurons to die.  Common in children of Eastern European Jewish ancestry.  It’s a degenerative disorder with infants of about 5 months.  They show an exagerated startle response and poor motor development.  17 % of sufferers live beyond 4yrs of age and those who do show rapid decline in cognitive, motor and verbal skills.  Its rare and occurs in 1/360,000 live births world wide and is reduced through effective screening. Low qty -fruits, veg,cereals,fats Vs High quantitied phenylalanine-meat, fish,eggs,cheese etc

24. PERINATAL CAUSES  Involves the period from conception to early postnatal period which is crucial as a baby’s rapid development is interfered with.  There are prenatal and postanatal factors that put normal development at risk and may cause life long intellectual disability  Factors that affect the foetus’s interuterine environment and its food supply. They are known as Congenital disorders-Prior to birth but are not genetically induced include: 1.Maternal infections, 2.substance abuse or 3.malnutrition. Characterised by slow dev’t, ID and small stature

25. Examples of Perinatal disorders  Congenital disorders: Disorders acquired during prenatal dev’t prior to birth but are not genetically inherited.  Maternal malnutrition: Mineral and vitamin deficiencies during pregnancy can result into ID, and affect the physical and behavioural dev’t.Other include; i.Congenital rubella syndrome-CRS: The constellation of abnormalities caused by infection with rubella(German measles)virus before birth- Characterized by multiple congenital malformations and ID-birth defects. ii.Maternal HIV Infection: The incidence of a mother having HIV during pregnancy, leading to a likelihood that the infection will be passed onto the foetus. However correction can be done throgh providing intellectual supportive environment and appropriate food suppliments.

26. Conti.. i.Fetal alcohol syndrome –FAS: Maternal drug abuse causing Childhood ID. Alcohol drunk here enters the foetus’s blood stream and slows down the body’s metabolism and dev’t is affected if its done on a regular basis. Characterized by Low weight, lower IQ OF 40 and 80 and suffer motor impairments and deficits in attention and working memory. Features: Slit eyes, short noses ii.Crack baby: Baby addicted to cocaine due to use by mother during pregnancy.  Anoxia: prenatal cause of ID, and is a significant period without oxygen that occurs during or immediately after delivery. It damages part of the brain hence ID affected. Cerebral palsy-neurological birth syndrome caused by Anoxia. Characterized by motor symptoms that affect and coordination of movement.

27. CHILDHOOD CAUSE  Although born health a number of factors may occur to alter the normal dev’t. They may also occur in conjuction with prenatal problems,These include; 1.Accidents and injury:As children may be involved in severe accidents such as falls,car accidents, near drowning, suffocation and poisoning.Others may be due to physical abuse by others.Retrospective Case-head injury in children 1-6yrs at 81%by defined accidents but 19% due to abuse such as Shaken baby syndrome-Traumatic brain injury that occurs when a baby is violently shaken. 2.Exposure to toxins:Toxins in early development cause neurological damage such as lead and mercury. Esp in low SES which accumulate and interfear with the brain and CNS. In Europe 1-2yrs with prevalence of % of lead poising and are higher in LDCs

28. Conti.. 1.Childhood infections: Due to underdeveloped brains of children are likely to get infected with disease such as meningococcal meningitis and encephalitis hence neurological damage of the infants. 2.Poverty and deprivation:Teenage mothers deprive children because there is decreased stimulation such as sensory and educationall stimulation, lack one on one child parent r/ship,and povery of verbal communication.

29. Intervention Treatment depends on the severity of the Id, to improve the limitations in individual and societal functioning. Support is meant to help the individual cope with challenges such as education, occupation, economic and social.Institutionalization is old fashioned. Interventions: 1.Primary level-AIM:  Is prevention of the disability through educating potential parents about the risk factors.  Make available training programmes that will provide sufferes with enough basic skills to cope with the daily life challenges such as self help skills and communication skills.  Approaches to help those with disabilities on the INCLUSION Principle: 1.to achieve their potential. Schools in the UK draw up accessibilty strategies to allow pupils with ID to engage in educational process withouit being disadvantaged. 2.To provide the disabled with opportunities for personal, social, emotional and sexual development.

30. Conti.. of Intervention 1.Prevention Strategies 2.Training procedures 3.Inclusion strategies

31. PREVENTION Risk factors especially prenatal causes, and maternal factors during pregnancy such as Foetal Alcohol Syndrome. Diagnostic and screening questionnaires -Prevents aims to identify the women at risk of alcohol abuse during pregnancy and to provide them with alcohol-reduction counselling. Intervention involves giving feed back on rates of drinking behavior during prenacy and discussing strategies for avoidng alcohol cravings and binge drnking. Others:Genetic analysis and counselling/blood tests and those of amionitic fluid done. And support programmes to foexample help teenage mothers improve.

32. TRAINING PROCEDURE. Basic training procedures to equip the skills lacked such self help skills and adaptive skills (say toileting,feeding), language and communication skills (speech, comprehension and sign language), leisure and recreational skills. Behavioral techniques such as the operant and classical conditioning. Learning theory to train in by Applied Behaviour Analysis- Applying the principle of learning theory-operant conditioning to the assessment and treatment of individuals. Funtional analysis-ABC.A-what happens before challenging behavior?what does individual do? What is is the reward or punishment?

33. INCLUSION STRATEGIES Evaluate the individual needs to suggest strategies,services and support that elevates their functioning both individually and society wise. In the UK, is the Special Education Needs (SEN)-Identifies those who require instruction or education tailored to their specific needs. SEN-Involves: 1.Mainstream schools provide the skills and specialist support. 2.Provide special schools for severe and complex needs. 3.Schools working together with local health services to support school inclusion from their community. 4.Ensure parents are confident with mainstream schools being efficient.

34. Conti.. Improvements noted: Coping skills in daily life and self esteem Decrease in maladaptive behaviour and aggression, anger and out bursts Improvement in self care and social skills Are now able to pursue careers. Employment opportunities are being made because many are conscientious and are valued workers employed in normal environments. Others with specific needs seek employment in sheltered workshops-Setting provide employment tailored in their own needs and abilities

35. Differential Specific learning disorder General intellectual impairments Autistic spectrum disorder Psychological and emotional problems Communication disorders

36. Comorbidity ADHD Anxiety disorders Autism spectrum Stereotypic mov’t disorders Impulse control disorders Major neurological disorders

37. Comparison DSM IV TR Disorders first diagnosed in Infancy, childhood, or Adolescence. Mental retardation 1.Mild -50-55 to approximately 70 2.Moderate- 35-40 to 50-55 3.Severe- 20-25 to 35-40 4.Profound mental retardation-below 20 or 25 5.Mental retardation severity unspecified. Unstable intelligence by test due to many impairments or uncooperative infants DSM 5 Neurodevelopmental disorders 1.Mild 317 (F70) 2.Moderate 318.0 (F71) 3.Severe 318.1 (F72) 4.Profound 318.2 (F73) Others 1.Global dev’tal 315.8 (F88)(under age 5 when severity is not met with failure to met dev’tal milestones) 2.Unspecified Intellectual Disability.over age 5 assessment limited by sensory impairment such as motor or deafness.

38. ICD-10 Mental Retardation 1.Mild mental redartion-F70 2.Moderate mental retardation-F71 3.Severe mental retardation-F72 4.Profound mental retardation-F73 5.Other mental retardation-F78 6.Unspecified mental retardation-F79 NB. A fourth character may be used to specify the extent of associate behavioural impairment.(No, or more minimal impairment, significant, other or without mention)

39. Reference Kaplan & Sadock, (2005) Comprehensive Textbook of Psychiatry, 8 th Edition; Lippincott Williams & Wilkins. William M. Wykylo and Jerald Kay, (2005): Clinical Child Psychiatry 2 nd Edi, Willey and Sons Ltd page 360-368.USA. Linda Wilmshurst, (2005):Essentials of Child Psychology: Essentials of Behavioral Science. John Wiley and Sons, Inc. New Jersey & Canada. Alan Carr, (2006):The handbook of Child and Adolescent Clinical Psychiatry: A contextual Approach ;Routledge, London. Graham Davey (2008):Psychotherapy; Research, Assessment and Treatment in Clinical Psychology, BPS textbooks in Psychology, USA. WHO, (1992):The ICD-10NcLASSICATION OF Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guideline, WHO, Switzerland

40. Differential Effects of Gender and Severity of MR-2013  Parents' Expectations About Future Outcomes of Children with MR in Kenya  Three constructs of parents' expectations about future outcomes for children with mental retardation in Kenya: 1.adult responsibilities, 2.community membership, and 3. educational attainment.  The purpose was to investigate changes in these constructs across child's gender and severity of mental retardation.  boys were found for the parents' expectations about future adult responsibilities  and educational attainment,  but not about community membership.  Overall, parents' expectations about future outcomes for children with severe mental retardation were much lower than those for children with mild or moderate mental retardation.