VIJAYA COLLEGE OF NURSING

PROGRAMME : M.SC NURSING II YEAR

NAME OF THE STUDENT : MRS. MERIN SOLOMON

SUBJECT : MENTAL HEALTH NURSING

UNIT : UNIT IX

TOPIC : INTELLECTUAL DISABILITY

SUBMITTED TO : PROF. SUBASHINDRAKUMAR C L

NAME OF THE EVALUATOR : PROF. SUBASHINDRA KUMAR C L

HOURS ALLOTED : 1 HOUR

SUBMITTED ON : 05-APRL-2020

INDEX

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SL NO CONTENT PAGE NO
I INTRODUCTION 2
II HISTORICAL DEVELOPMENT 3-4
III ICD 10 CLASSIFICATION 4
IV DEFINITION 5
V EPIDEMIOLOGY 5
VI CLASSIFICATION 5
VII ETIOLOGY 6-12
VIII SIGNS AND SYMPTOMS 12-14
IX PSYCHO PATHOLOGY 14-15
X DIFFERENTIAL DIAGNOSIS 15
XI DIAGNOSIS 15-18
XII TREATMENT 18-20
XIII CARE AND REHABILITATION OF 20-21
MENTAL RETARDATION
XIV NURSES ROLE 21- 26
XV SUMMARY 26
XVI CONCLUSION 26-27

XVII RESEARCH ABSTRACT 35-37

XVIII BIBLIOGRAPHY 38

I. INTRODUCTION

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 Intellectual disability (Mental retardation)is defined by deficits in general

intellectual functioning and adaptive functioning (APA 2000). General intellectual

functioning is measured by an individual’s performance on intelligence quotient (IQ)

tests. Adaptive functioning refers to the person’s ability to adapt to the requirements of

daily living and the expectations of his or her age and cultural group. The DSM-IV-

TRidentifies criteria for mental retardation as IQ of 70 or below, with deficits or

impairments in communication, self-care, home living, social/interpersonal skills, and use

of community resources, self-direction, functional academic skills, work, leisure, health,

and safety.

Identification of persons with mental retardation and affording them care and

management for their disabilities is not a new concept in India. The concept had been

translated into practice over several centuries as a community participative culture. The

status of disability in India, particularly in the provision of education and employment for

persons with mental retardation, as a matter of need and above all, as a matter of right,

has had its recognition only in recent times, almost after the enactment of the Persons

with Disabilities Act

(PWD), 1995.

II. HISTORICAL DEVELOPMENT

1. Pre-Colonial India

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 Historically, over different periods of time and almost till the advent of the

colonial rule in India, including the reigns of Muslim kings, the rulers exemplified as

protectors, establishing charity homes to feed, clothe and care for the destitute persons

with disabilities. The community with its governance through local elected bodies, the

Panchayati system of those times, collected sufficient data on persons with disabilities for

Provision of services, though based on the philosophy of charity. With the establishment

of the colonial rule in India, changes became noticeable on the type of care and

management received by the persons with the influence from the West.

2. Pre-Independence–Changing Life Styles in India

Changes in attitudes towards persons with disabilities also came to about with city

life. The administrative authorities began showing interest in providing a formal

education system for persons with disabilities, particularly for families which had taken

up residences in the cities. Changes in the lifestyle of the persons with mental retardation

were also noticed with their shifting from ‘community inclusive settings’ in which

families rendered services to that of services provided in ‘asylums’, run by governmental

or non-governmental agencies (Chennai, then Madras, Lunatic Asylum, 1841). It was at

the Madras Lunatic Asylum, renamed the Institute of Mental Health, that persons with

mental illness and those with mental retardation were segregated and given appropriate

treatment. Special schools were started for those who could not meet the demands of the

mainstream schools). The first residential home for persons with mental retardation was

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established in Mumbai, then Bombay followed by the establishment of a special school in

1944. Subsequently, 11 more centers were established in other parts of India.

3. Post-Independent India–Current Scenario

 Establishment of Special Schools

Article 41of the Constitution of India (1950) embodied in its clause the “Right to Free

and Compulsory Education for All Children up to Age 14 years”. Many more schools for

persons with mental retardation were established including an integrated school in

Mumbai (Sushila Ben, 1955). Notwithstanding this obligatory clause on children’s

mainstream education, more and more special schools were also being set up by

nongovernmental organizations (NGOs) in an attempt to meet the parents’ demands.

III. ICD 10 CLASSIFICATION

F70- F79 Mental retardation

F70 Mild mental retardation

F71 Moderate mental retardation

F72 Severe mental retardation

F73 Profound mental retardation

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 IV. DEFINITION

1. Intellectual Disabilityrefers to significantly sub average general intellectual

functioning resulting in or associated with concurrent impairments in adaptive

behavior and manifested during the developmental period. (American Association

On Mental Deficiency).

2. Intellectual disability is defined by deficits in general intellectual functioning and

adaptive functioning (APA 2000).

3. Intellectual disability is a generalized disorder appearing before adulthood,

characterized by significantly impaired cognitive functioning and deficits in two or

more adaptive behaviours. It has historically been defined as an intelligence quotient

score under 70. (Wikipedia)

V. EPIDEMIOLOGY

About 3 percent of the world population is estimated to be mentally retarded. In

India 5 out of 1000 children are mentally retarded. Mental retardation is more common in

boys than girls with severe and profound mental retardation. Mortality is high due to

associated physical disease.

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 VI. CLASSIFICATION

Intelligence quotient (IQ) is the ratio between Mental Age (MA) and chronological

Age (CA). While the chronological age is determined from the date of birth, mental age

is determined by intelligence tests.

Mental age

IQ= --------------------------------*100

Chronological age

TYPE INTELLIGENCE QUOTIENT

Mild( Educable) 50- 70
Moderate (Trainable) 35- 50
Severe( dependent retarded) 20- 35
Profound(life support) <20

VII. ETIOLOGY

The causes of ID can be grouped from most to least common as follows:

 Alterations in embryonic development, such as those caused by chromosomal

abnormalities or fetal exposure to drugs or toxins.

 Environmental deprivation and other mental disorders, such as autism.

 Problems of pregnancy and the perinatal period, such as fetal malnutrition,

hypoxia, infection, trauma, or prematurity.

 Hereditary abnormalities, such as inborn errors of metabolism or chromosomal

aberrations

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  Medical conditions of infancy or childhood, such as central nervous system (CNS)

infection or trauma, or lead poisoning

I. PSYCHO BIOLOGICAL CAUSES

 Genetic factors

Prenatal genetic disorders are characterized by changes in the genetic material, which

may or may not have been inherited from the parents. Prenatal genetic disorders are

characterized by changes in the genetic material, which may or may not have been

inherited from the parents. Recent advances in the science and understanding of genetics

have allowed a higher diagnostic yield from such testing.

 Chromosomal aberrations

A) Down syndrome

Down syndrome is the best-known example of a prenatal genetic disorder. In 95%

of cases, Down syndrome is caused by trisomy 21, in which the extra chromosome 21 in

the egg or sperm cell results from the nondisjunction in the meiotic stage.  When such a

gamete becomes fertilized, the fetus will have an extra chromosome 21 in all cells, for a

total of 47 chromosomes.

 Disorders with autosomal-dominant inheritance

Tuberous sclerosis is an example of the disorders in this group, which might be

associated with ID. It is caused by a mutation in a gene affecting the formation of the

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ectodermal layer of the embryo. Because the skin and the CNS develop from this layer,

abnormalities are seen in both.

 Disorders with autosomal-recessive inheritance

Most metabolic disorders belong to this category. They are caused by single

mutated genes that disturb the metabolism by deficient enzyme activity. The risk of

healthy carrier parents having an affected child is 25% for each pregnancy. The diagnosis

is made by detection of abnormal metabolic products in the urine, blood, or tissues and/or

by low or absent enzyme activity.

Phenylketonuria (PKU) is the best known and most common of the metabolic

disorders, with a prevalence of approximately 1 in 10,000 live births. The enzymatic

defect is diminished activity of phenylalanine hydroxylase, which leads to a high serum

phenylalanine level, affecting, among other things, myelination of the CNS. It was

described in 1934 in 10 children with ID, hypertonia, and hyperreflexia, with a musty

odor in urine and sweat. Seizures and tremors are common, as are eczema and psychotic

manifestations.

 X-linked mental retardation

Fragile X syndrome is the most common inherited form of mental retardation and,

after Down syndrome, the most common genetic form. It is X linked, with dominant

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inheritance, and the penetrance is lower in females. Because of a constriction at the

location Xq27.3, it appears as if the chromosome is fragile and a part of it is breaking off.

Prepubertal boys with this syndrome look quite normal. They often are restless

and hyperactive and have a short attention span. Their developmental milestones,

especially speech development, are delayed. After puberty, the characteristic

phenotypical features may appear. They include an oblong face, prominent ears and jaw,

and macroorchidism. Most have moderate mental retardation, but retardation is more

severe in others. Male carriers do not have mental retardation. Females with fragile X

syndrome who have the full mutation and are symptomatic usually have learning

disabilities or mild mental retardation. Behavioral symptoms have been described in these

individuals, ie, hyperactivity and social withdrawal in approximately 50% and depression

in approximately 25%.

 Maternal infections

Viral infections in the mother can interfere with organogenesis, and the earlier in

pregnancy they occur, the more severe their effect will be, as exemplified by

congenital rubella. Rubella infection during the first month of pregnancy affects the

organogenesis of 50% of embryos. Infection in the third month of pregnancy still disturbs

the development of 15% of fetuses. Various systems are affected, and as a result,

symptoms and impairments may vary and include mental retardation, microcephaly,

hearing and vision impairment, congenital heart disease, and behavior problems.

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Fortunately, the incidence of congenital rubella has greatly decreased because of the

availability of immunization for prospective mothers.

 Toxic substances

The most important of the teratogenic substances is ethanol, which is the cause

of fetal alcohol syndrome (FAS). The prevalence of this syndrome varies around the

world, but its occurrence in industrialized countries is estimated to be approximately 1 in

1000 newborns. When used heavily during pregnancy, alcohol causes abnormalities in 3

main categories: (1) dysmorphic features, which originate in the period of organogenesis;

(2) prenatal and postnatal growth retardation, including microcephaly; and (3) CNS

dysfunction, including mild-to-moderate mental retardation, delay in motor development,

hyperactivity, and attention deficit. The severity of the symptoms is related to the amount

of alcohol ingested.

 Toxemia of pregnancy and placental insufficiency

Growth retardation has many causes, the most important being maternal toxemia

with its consequences, ending in insult to the CNS. Prematurity may be of maternal or

fetal origin. When it is connected with fetal developmental deviations, the prognosis

depends on the infant's general condition. Prematurity and especially intrauterine growth

retardation predispose to many perinatal complications, which may result in insult to the

CNS and developmental problems

 Perinatal Causes

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This period refers to 1 week before birth to 4 weeks after birth.

 Infections

During the neonatal period, the most important infection, from the point of view of

its developmental sequelae, is herpes simplex type 2. The neonate is infected during the

delivery and may develop encephalitis within 2 weeks. Early treatment with acyclovir

may alleviate the otherwise poor outcome, ie, microcephaly, profound mental retardation,

and neurological deficits. Neonatal bacterial infections might result in sepsis and

meningitis, which, in turn, may cause hydrocephalus.

 Delivery problems

During delivery, asphyxia is the most important factor causing an insult to the

CNS. It leads to cell death, which might be demonstrated with neuroimaging techniques

as leukomalacia. Premature infants and those with intrauterine growth retardation are at

special risk for damage to the cortex or thalamus, which, in addition to affecting

intelligence, causes various symptoms of cerebral palsy (CP) and seizure disorder,

depending on the location of the pathological condition. Importantly, note that asphyxia

alone does not cause mental retardation.

Neurologic symptoms during the neonatal period have a strong association with prenatal

developmental deviations and later neurologic integrity and intellectual level. For these

reasons, infants with perinatal problems need a thorough examination for dysmorphic

features and close follow-up because multiple disabilities might become evident later in

life.
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  Other perinatal problems

Retinopathy of prematurity (formerly referred to as retrolental fibroplasia) was

seen frequently when the use of 100% oxygen in neonates was common, resulting in

blindness. It is often associated with other CNS damage, mental retardation, and other

developmental problems.

Infants with extremely low birth weight are at risk for intracranial hemorrhage

and hypoglycemia resulting from a lack of hepatic glycogen storage. These neonatal

problems may have results similar to those of asphyxia.

Hyperbilirubinemia may result from increased destruction of red cells (eg,

hemolysis due to maternal-child blood group incompatibility) or decreased excretion of

bilirubin (eg, due to an immaturity of liver function).

The brain damage that may ensue results in manifestations of various degrees,

including CP, sensorineural hearing loss, and mental retardation.

 Postnatal Causes

 Infections

Bacterial and viral infections of the brain during childhood may cause meningitis

and encephalitis and result in permanent damage. The number of these complications has

decreased because of improved treatment and the availability of immunizations such as

that for measles.

 Toxic substances

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 Lead poisoning is still an important cause of mental retardation in the United

States. The most frequent source of lead is pica (ie, ingestion of flaking, old, lead-based

paint). Other sources of lead are certain fruit-tree sprays, leaded gasoline, some glazed

pottery, and fumes from burning automobile batteries. Gastrointestinal symptoms

dominate in acute poisoning. Headache may be associated with increased intracranial

pressure, which may even lead to coma. Late manifestations include developmental

retardation, ataxia, seizures, and personality changes.

 Other postnatal causes

Among childhood malignancies, brain tumors are second in frequency after

leukemias. Of these, 70-80% are gliomas, symptoms of which depend mostly on

location. Some are benign and treatable, but most have deleterious effects, resulting in

various neuropsychiatric symptoms depending on their location and extent. In

addition, treatment such as surgery and radiation might affect the integrity and

function of the brain. Traffic accidents, drowning, and other traumas are the most

common causes of death during childhood. Even greater is the number of children

who become disabled. Near-drowning is often devastating, but even in these cases,

improvement of functional capacity may be achieved by rehabilitation because the

developing brain has the ability to recover.

II. PSYCHOSOCIAL PROBLEMS

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 The developmental level of a growing individual depends on the integrity of the

CNS and on environmental and psychological factors. The importance of environmental

stimulation for child development has been appreciated since research on children in

institutions showed that development was severely affected in a depriving environment,

even if adequate physical care was provided. Poverty predisposes the child to many

developmental risks, such as teenage pregnancies, malnutrition, abuse, poor medical care,

and deprivation.

Severe maternal mental illness is another risk factor. Mothers with severe and

chronic illness might have difficulty providing adequate care and stimulation. Maternal

depression during pregnancy and postpartum has been shown to be associated with

developmental delay in children at 18 months of age. 

Children of mothers who have schizophrenia are at risk for the development of

cognitive deficits, although these may not be secondary to maternal illness but may

represent a genetically determined predisposition to schizophrenia. Psychotic illness in a

child has been shown to be associated with a decline in cognitive abilities.

 Unknown causes

Despite detailed assessment, no cause can be identified in approximately 30% of

cases of severe mental retardation and in 50% of cases of mild mental retardation. This,

of course, reflects the inadequacy of diagnostic techniques, rather than a lack of

causation.

VIII. SIGNS AND SYMPTOMS

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 According to the latest edition of the diagnostic and statistical manual of mental

disorders(DSM IV), three criteria must be met for a diagnosis of mental retardation: an

IQ below 70, significant limitations in two or more areas of adaptive behavior (as

measured by an adaptive behavior rating scale, I.e. communication, self help skills,

interpersonal skills, and more), and evidence that the limitations became apparent before

the age of 18. It is formally diagnosed by professional assessment of intelligence and

adaptive behavior. The common signs and symptoms are;

 Failure to achieve developmental milestones

 Deficiencies in cognitive functioning such as inability to follow commands or

directions

 Reduced ability to learn or to meet academic demands.

 Expressive or receptive language problems

 Psychomotor skills deficits

 Difficulty performing self care activities

 Neurologic impairments

 Medical problems such as seizures

 Low self esteem

 Irritability when frustrated

 Acting out behavior

BEHAVIOURAL MANIFESTATIONS OF MENTALLY RETARDED CHILDREN

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 mild retardation Moderate retardation Severe retardation Profound
retardation

Self-care The child may be able to The child requires close The child requires complete The child requires
ability live somewhat supervision and must be supervision but may be able constant
independently with supervised when to perform simple hygiene assistance and
monitoring or assistance performing certain skills such as brushing teeth supervision.
with life changes, independent activities. and washing hands.
challenges, or stressors
(such as personal illness or
the death of a loved one).
Education The child can achieve The child can achieve May learn a few simples The child cannot
level reading skills up to the level skills up to second class benefit from
of primary school and and may be trained in skills academic training
master vocational training to participate in a
workshop setting
Social skills The child can learn and, The child has certain The child has limited verbal The child has little
social sikllin structured speech limitations and skills and tends to speech
settings. difficulty following communicate needs non development and
expected social norms. verbally or by acting them lacks social skills.
out.
Psychomotor The child can develop The child may have The child has poor The child lacks
skills average to good skills but difficulty with gross motor psychomotor skills, with both fine and
may experience minor skills and may have limited limitedability to perform gross motor skill
coordination problems vocational opportunities. simple tasks even under
direct supervision
Economic The child can perform a job The child may learn to The child may be taught how The child must
situation under close supervision and handle a small amount of to use money and supervised depend on others
manage money with proper pocket money as well as while shopping for money
guidance how to make change. management.

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 IX. PSYCHO PATHOLOGY

Birth defects that cause physical deformities of the head, brain, and central nervous

system frequently cause mental retardation. Neural tube defect, for example, is a birth

defect in which the neural tube that forms the spinal cord does not close completely. This

defect may cause children to develop an accumulation of cerebrospinal fluid inside the

skull (hydrocephalus). Hydrocephalus can cause learning impairment by putting pressure

on the brain.

Extracellular guidance cues (ligands) interact with growth cone, synaptic and

membrane receptors and activate signaling cascades that involve RhoGTPases. Activated

RhoGTPase pathways control actin/microtubule cytoskeleton dynamics, which in turn

regulate changes of growth cone, neuronal and synapse morphogenesis and activity

Interestingly, the dysfunction of these pathways through loss of function of PAK3

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(p21activating kinase), OPHN1 (RhoGAP), TM4SF2 (teraspanin), ARHGEF (RhoGEF)

and FMRP (fragile X mentalretardationprotein)leadtoMR.

X. DIFFERENTIAL DIAGNOSIS

- Deaf and dump

- Deprived children with inadequate social stimulation

- Isolated speech defects

- Systemic disorders

- epilepsy

XI. DIAGNOSIS

The psychiatric diagnostic evaluation of persons with mental retardation is, in principle,

the same as for persons who do not have retardation. The diagnostic approaches are

modified, depending on the patient’s cognitive level and, especially, communication

skills. The assessment includes the following components:

1. Comprehensive history: includes presenting symptoms, psychiatric review of

systems, details of previous psychiatric treatment, past and present educational and

rehabilitative interventions, work programs and living situations, parents/caregivers

attitudes towards the patient, their understanding of the patient’s disability and

support for growth versus overprotection and review of past cognitive tests and

evaluations or request for new ones if needed.

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2. Patient interview: including the verbal examination should be adapted to the

patient’s communication skills and should use clear and concrete language, structure,

reassurance and support.

3. Mental status examination: may be assessed in the context of conversation, rather

than in a formal examination. Starting the interview with a discussion of a patient’s

strengths and interests, rather than problems, often is helpful

4. Medical review includes: this review should include developmental and medical

history, past etiological assessments and coexisting general medical disorders and

their treatments.

5. Screening

Screening is a procedure for an initialidentification of persons with mental retardation

and for a follow up with assessment.

Screening Procedure

Many of the screening techniques collated by National Institute for the

MentallymHandicapped (NIMH), Secunderabad, appeared in RCI: Status of Disability in

India, 2000.

A more systematic process and procedure has been the pooling of a battery of tests on

clinicalinvestigations by the NIMH, for identification and screening of persons with

mental retardation. They include pre-natal, neonatal and post-natal diagnostic procedures:

(i) Pre-natal Procedures

Blood tests for the pregnant mothers for any anemic condition, diabetes, syphilis,

Rh incompatibility and neural tube defects in the foetal stage.

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• Ultrasonography(during pregnancy) is carried out in the second trimester of pregnancy

to detect such disorders as neural tube defects, hydrocephaly,microcephaly,

hydrencephaly, holoprosencephaly, prosencephaly and some cerebellar lesions. Intra-

uterine growth retardation can also be detected through such measurements as

foetalbiparietal diameter, crown rump lengtand transverse abdominal diameter.

 Aminocentesis

Is indicated in cases of foetal chromosomal aberration, congenital metabolic errors

and open, neural tube defects, severe Rh incompatibility and also in cases of advanced

maternal age with previous birth history of anabnormal child. Aminocentesis is a

procedure for purposes of earlyidentification and primary preventionfor many genetic

abnormalities.

• Foetoscopy

Is done during second trimester of pregnancy in diagnosingcertain physical

anomalies, metabolicdisorders or biochemical abnormalities.

• Chorionic Villous Sampling

Where a biopsyof the chorionic villi is performed eithertransabdominally or

vaginally. Thesample is then subjected to karyotypingand enzyme determination.

(ii) Neonatal and Post-natal Screening and Diagnostic

Blood and urine examinations are conducted in the neonatal period in all suspected

cases and with a previous history of mental retardation in the family. Cretinism is another

condition which can be diagnosed in the neonatal period and necessary treatment given.
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• Apgar Score at one minute after delivery is an index of asphyxia and the need for

assisted ventilation.

• Urine screening for metabolic errors PKU (PhenyleKetoneuria).

• Blood biochemistry tests for cretinism, rickets, jaundice.

• Blood antibody titrates to detect infections.

• Chromosomal analysis for Down syndrome, deletion of syndromes.

• Neonatal neurobehavioural assessments.

• Screening for visual impairments (visual acuity, fundus examination, retinoscopy).

• Screening for hearing impairments (Tympanogram, BERA.)

• Ultra sonogram.

• Ultra Sound Examination:The technique can be used to detect displacement of brain

midline structures, thickness of brain substance, and pathological cavities in the brain.

Real-time ultrasound examination of the head can reveal intracranial hemorrhage in the

newborn.

• Biochemical Tests in neonatal screening for identifying metabolic disorders.

• Electro Encephalography (EEG):EEG is useful not only in epilepsy, but in many other

cases of mental retardation and organic brain lesions. In certain cases it also helps in

localization of lesions and the severity of a cerebral damage. Incidence of abnormal

EEGs is higher in cases of mental retardation associated with epilepsy, encephalitis,

severe degree of mental retardation and brain damage sustained before birth or during

birth or in the early period of infancy.

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• Computerised Tomography (CT):There are many abnormalities which can be detected

by CT scan of the CNS, such as, anoxia of tissue, intracranial haemorhage,

hydrocephalous and congenital anomalies

 Magnetic Resonance Imaging (MRI):This screening helps in identifying a large

number of persons with suspected disability in a limited time period.

PROGNOSIS

The prognosis for children with mental retardation has improved and institutional

care is no longer recommended. Their children are mainstreamed whenever feasible and

are taught survival skills. A multidimensional orientation is usedwhen working with these

children, considering their physiological, cognitive, social and emotional development.

XII. TREATMENT MODALITIES

 PREVENTION

1. Primary Prevention

 Preconception

 Genetic counseling, which is an attempt to determine risks of occuttence or recurrence

of specific genetic or chromosomal disorders; parents can then make an informed

decision as to the risks of having a retarded child

 Immunization for maternal rubella

 Blood tests for marriage licenses can identify the presence of venereal diseases

 Adequate maternal nutrition can lay a sound metabolic foundation for later

childbearing.

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 Family planning in terms of size, appropriate spacing, and age of parents can also

affect a variety of specific casual agents.

 During gestation

Two general approaches to prevention are associated with this period

a) Prenatal care

- Adequate nutrition, fetal monitoring and protection from disease.

- Avoidance of teratogenic substances like exposure to radiation and

consumption of alcohol and drugs.

b) Analysis of fetus for possible genetic disorders

- By amniocentesis, fetoscopy, fetal biopsy and ultrasound

 At delivery

 Delivery conducted by expert doctors and staff, especially in cases of high risk

pregnancy (for example, maternal conditions of diabetes, hypertension, etc.)

 Apgar scoring done at 1 and 5 minutes after the birth of the child.

 Close monitoring of mother and child.

 Injection of gamma globulin, which can prevent Rh- negative mothers from

developing antibodies that might otherwise affect subsequent children.

 Childhood

 Proper nutrition throughout the developmental period and particularly during the first

6 months after birth.

 Dietary restrictions for specific metabolic disorders until no longer needed.

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 Avoidance of hazards in the child’s environment to avert brain injury from causes

such as lead poisoning, ingestion of chemicals, or accidents.

2. Secondary prevention

 Early detection and treatment of preventable disorders. For example, phenylketonuria

and hypothyroidism can be effectively treated at an early stage by dietary control or

hormone replacement therapy.

 Early recognition of presence of mental retardation. A delay in diagnosis may cause

unfortunate delay in rehabilitation.

 Psychiatric treatment for emotional and behavioral difficulties.

3. Tertiary prevention

 Treatment of psychological and behavioural problems.

 Behavior modification

 Rehabilitation in vocational, physical and social areas.

 Parental counseling

 Institutionalization for individuals with profound mental retardation.

XIII. CARE AND REHABILITATION OF MENTAL RETARDATION

The aims and objectives of rehabilitation programmes are

I. To increase the awareness of the community and to sensitize it to issues and bring

about a positive attitudinal change.

2. To facilitate bringing patients and their families into the mainstream.

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3. To mobilize community resources and enhance community participation in building

the required services.

4. To establish accessible, available and affordable services for the majority of people

within the community itself.

5. To ensure that these people and their families have a say in how the services are run.

6. To have psychiatric and psychological services for mentally retarded child.

7. To have regular assessment for mentally retarded children.

8. Promote ownership of the programmes by the community itself so that they continue

even without external aid or support.

Multidisciplinary treatment terms use a variety of psychosocial modalities to address

behavioral problems experienced by patients who are mentally retarded. The behavioural

interventions recommended by the expert consensus panel for most situations are;

I. Medical and Psychological (clinical) Services :

The first requirement for appropriate facilities for a good medical/ health

evaluation and accurate diagnosis. Doctors should be in a position to recognize and

manage treatable disorders such as hypothyroidism. Associated problems such as

convulsions, sensory impairments and behavior problems can be corrected or controlled

with proper medical attention.

2. Parental Counseling:

Adequate parental counseling in the initial stages is essential. Parental counseling

also involves providing emotional support and guidance, and strengthening morale. Once

theparents get a grasp of the condition, they need to learn appropriateways of rearing and

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training the child. Parents continue to need such assistance, guidance and support as the

child grows up, especially during adolescence, early adulthood and during periods of

crisis.

3. Early Detection and Early Stimulation:

Many well-conducted research studies have clearly shown that detecting mental

retardation at an early stage that is, in infancy, and providing a loving and stimulating

environment helps these children to develop better and prevents many complications.

Parents should be alert when the child is premature, have delayed milestone, repeated

convulsions, inactive babies, & dependent for self-care.

4. Training in Self-help, Social and Practical Skills:

Children with mental retardation often do not learn skills for activity of daily

living on their own. Through systematic efforts and using proper techniques, it is possible

to teach and train them in these skills. Behavior modification techniques are very useful

and effective n teaching. These include:

• Rewarding or positive reinforcement

• Modeling

• Shaping

• Chaining

• Physical guidance

5. Speech Therapy :

Mental retardation is often accompanied by a significant limitation in the

development of speech and language. Research has again shown that a systematic

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application of speech therapy techniques is effective in promoting speech, language and

communication.

6. Education:

Children with mental retardation need to be imparted education like other

children.Through they are slow in learning, experience and research has shown that by

applying the right kind of educational techniques, it is possible to impart the basic skills

of reading, writing and arithmetic to many with mental retardation. The current approach

is to educate them, as far as possible, in normal schools, rather than setting up special

schools.

7. Vocational training:

Potential jobs can be manual, unskilled or semiskilled, depending on the

capabilities of the individual. It should be remembered that such gainful occupation is not

only possible but also helpful for the mental health, self satisfaction , and social status of

these individuals.

8. Residential Care

There is no doubt that the best place for people with mental retardation to grow up

in is their own family. On the other hand, one issue that it is the possibility that their

retarded child may outlive them.

9 Individual and Family approaches:

Mental retardation is generally a lifelong condition and it cannot be cured with

medical treatment. Given this fact, what can be done and what should be the aim and

objectives in providing care for these individuals? The following considerations should

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be kept in mind to guide actions such as scientific evidence, humanistic need, family

perspective, normalization, & integration.

10. Home-based Care with Parents as Partners:

Research has shown that the best place for children with mental retardation to

grow in is their own families, where they can be nurtured with appropriate stimulation.

Therefore, services should be organized so that the families are supported, strengthened

and empowered to look after their affected member.

11. Community-based Approaches

A community orientation is necessary, so that services are available to large

sections of society in their own vicinity. No programme is likely to succeed without

community involvement and participation.

XIV. NURSES ROLE

 Prevention of mental retardation:

 Give genetic counseling to the couple if there is history of MR in the family.

 Prevent the mother from having any typr of infection during pregnancy.

 Encourage abortion if the mother had rubella infection.

 Enroll the mother for a regular antenatal checkup

 Educate the couple for delivery in a good hospital with adequate facilities.

 Protect the infant from any type of infection

 Explain the mother about the growth and development of the child. It will help to

identify the delay developmental milestone.

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 Assessment of degree of mental retardation

 Encourage parents to bring the child to a well baby clinic regularly.

 Check for the milestones and teach the mother- ensure any physiological handicap

before informing or creating doubt in parents about MR especially deafness.

 Help handling anxiety of parents

 Psychosocial support

1. Acceptance of child with mental retardation

- Encourage parents to talk about the report

- Listen patiently and with supportive attitude

- Educate parents that home environment is safe for the child psychologically

and physically.

- Encourage mother to clarify her doubts at each stage of child development.

- Explain that they don’t have to be ashamed of having a MR Child at home.

2. Help parents in developmental changes

- Prepare parents to accept the physical growth of the child.

- Train and care for a female child during her menstruation

- Do not leave a young girl alone at home with a male MR client.

- Control and punish the impulsive behavior of the child.

- Do not overprotect.

3. Help in communication

- Help parents to use simple names and ask the child to repeat Dad, mom, names

of toys, dolls etc.

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 - Call by name people at home

- Give reward when the client tries to call a correct name

4. Improve attention and concentration

- To help the client to familiarize and learn about things in his nearby

environment.

- Explain to parents to give one activity at a time like taking out water with a

mug from one bucket till it empty.

- Encourage the client to repeat these activities.

5. Help in fostering group behavior

- Allow the child to attend group activities.

- Help the child to learn behavior which is accepted in the group such as not

throwing things here and there.

- Be quiet when guest have come.

6. Help coming with physical stimulation of senses

Goal:stimulation of senses that in eye, ear, skin and nose. They will also help the

client to start identifying things.

- Put te bed near the window so that the client can see a variety of things.

- Use bright colours

- Name the color repeatedly

- Allow the child to listen to music and sound

- Put the child over a blanket, smooth cloth, rough cloth

- Show a picture of flower repeatedly, then show the real flower and say ‘flower‘

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 Physical needs

1. Train the child for personal hygiene(care of skin and teeth)

Goal: To help the client to learn self care

- Take a brush and hold it in your hand

- Tell the child to hold it in your brush and the child’s brush

- Make the child repeat it

- Open your mouth, put teeth together and brush

- Step by step see the child repeats

- Take the child to the bathroom

- Demonstrate bathing procedure step by step like brushing

- Repeat activities for several days/weeks

- Show happiness at each positive act of the child

2. Helping in dressing

- Demonstrate buttoning and unbuttoning of the shirt without wearing it.

- Explain to the parents to give cloths with big holes and buttons. No back

buttons, use press buttons.

- Get bright coloured cloths for the child with a picture on them.

- Give these to the child and tell him these belong to himthesebelomg to him

/her.

3. Helping in toilet training

- Ask children to pass urine in the toilet in front of the mr child

- Demonstrate to the child how to sit in the toilet

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4. Training in eating

- Take a slice of bread and hold it in your fingers

- Tell the child to do the same

- Help in putting the bread slice in his/her fingers

- Open your mouth and bite a small piece

- Now ask the child to repeat the same

- Chew slowly

- Ask the child to chew

- Swallow it in front of the child

 Recreational activities

Goal: To help the client join the group in play to attain pleasure

- Provide simple craft activity like folding paper in two

- Playing with mud and making small toys

- Coloring a toy with one or two colors

- Providing the child to paint what he/she like

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 XV. SUMMARY

This seminar we discussed about definition, Mental retardation refers to

significantly sub average general intellectual functioning resulting in or associated with

concurrent impairments in adaptive behavior and manifested during the developmental

period. (American Association on Mental Deficiency). About 3 percent of the world

population is estimated to be mentally retarded. In India 5 out of 1000 children are

mentally retarded. The main classification are mild, moderate, severe, and profound. The

main etiological factors are genetic factors, prenatal factors, intranatal factors, postnatal

factors and socio environmental factors. The diagnostic measures mainly include history

collection, mental status examination, and screening methods such as CT, MRI, etc. The

prevention mainly include primary prevention, secondary and tertiary prevention.

XVI. CONCLUSION

Intellectual Disability (ID), also known as general learning disability, and mental

retardation (MR), is a generalized neurodevelopmental disorder characterized by

significantly impaired intellectual and adaptive functioning. It is defined by an IQ under

70 in addition to deficits in two or more adaptive behaviors that affect every day, general

living.

Once focused almost entirely on cognition, the definition now includes both a

component relating to mental functioning and one relating to individuals' functional skills

in their environments. As a result of this focus on the person's abilities in practice, a

person with an unusually low IQ may not be considered to have intellectually disability.

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 Intellectual disability is subdivided into syndromic intellectual disability, in which

intellectual deficits associated with other medical and behavioral signs and symptoms are

present, and non syndromic intellectual disability, in which intellectual deficits appear

without other abnormalities. Down syndrome and fragile X syndrome are examples of

syndrome intellectual disabilities.

XVII. RESEARCH ABSTRACT

THE EFFECT OF INTELLECTUAL DISABILITY ON TRANSITION

PREPARATION TO ADULT HEALTHCARE

 Christine James, MSW, LSW, PhD Student, Rutgers University, New Brunswick, NJ

LennaNepomnyaschy, PhD, Associate Professor, Rutgers University, New Brunswick,

NJ

Background and Purpose:

Approximately 500,000 U.S. youth transition annually from pediatric to adult

healthcare systems and some experience serious gaps in outcomes. One prior study found

that most youth with special health care needs are not receiving needed transition

preparation from health care providers to transfer from pediatric to adult healthcare,

including attention to maintaining insurance coverage. In addition, parents of young

adults with intellectual/developmental disabilities have reported that the transition period

is a source of stress, and this population experiences a longer and more complex

transition period to adulthood.

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Study Aim, Research Question, & Hypothesis: This study aims to identify whether

there is an association between youth with intellectual disabilities and receipt of

healthcare transition preparation, including what factors may influence this preparation.

The research question examined is: Does presence of intellectual disability have a

negative effect on transition preparation to healthcare? This study proposes that youth

with intellectual disability are not as prepared for transition to adult healthcare as youth

with physical disabilities.

Methods:

This study utilizes data from the 2009-2010 National Survey of Children with

Special Health Care Needs, a nationally representative sample of more than 40,000 parent

respondents who have youth with special health care needs. Transition preparation

questions are asked of parents with youth ages 12 – 17, with a total of 17,114 interviews

conducted. The sample for this study includes 14,167 respondents who had a response on

all variables included in the full multivariate models. Transition preparation questions

consist of whether doctors have discussed the shift to an adult health care provider, future

health care needs, future insurance needs, and/or how often the youth has been

encouraged to take responsibility for his/her own health care needs.

Measures & Statistical Analysis:

Intellectual disability was defined as having a diagnosis of autism, mental

retardation, and/or Down syndrome. Physical disability was defined as having a diagnosis

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of cerebral palsy, muscular dystrophy, epilepsy, and/or cystic fibrosis. Using transition

preparation questions as a 4-point scale for the outcome variable, multivariate logistic

regression models were utilized to identify the effect of intellectual or physical disability

on transition preparation and identified 12 control variables that could potentially

influence this outcome variable.

Results:

Results of regression models indicate that there is a strong and negative

relationship between intellectual disability and transition preparation, and that this effect

holds true even after controlling for demographics, socioeconomic status, health

conditions, and insurance coverage. Preliminary findings indicate intellectual disability is

associated with poor transition preparation to adult healthcare, while physical disability

does not appear to have an effect on transition preparation score, as hypothesized.

Conclusions and Implications:

The findings of this study indicate that focused attention on the transition preparation

of youth with intellectual disability is both important and necessary to prevent serious

gaps in health care and service needs. Future steps for this study include identifying

potential variables and interaction effects that could be moderating this relationship

between intellectual disability and poor health care transition preparation.

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 XVIII. BIBLIOGRAPHY

Books

1. R.Sreevani, (2008).A Guide to Mental Health and Psychiatric Nursing, third edition,

jaypee publication, page no; 222-226.

2. C.L. Subash Indra Kumar (2014). A Text Book Of Psychiatry And Mental Health

Nursing, first edition, EMMESS publication , page no; 493-496

3. Anbu T (2010) Text book of Psychiatric Nursing, first edition EMMESS publication,.

4. JN Vyas and Niraj Ahuja, (2008).Textbook of Postgraduate Psychiatry, second

edition, Jaypee publication, page no; 572-586.

5. Mary C Townsend ,(2015). Psychiatric Mental Health Nursing, Concepts of care in

evidence based practice, eight edition, page no; 705- 709.

Net resources

1. www.wikiepedia.com

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