Intellectual Disability

Dr. Joslin Dogbe Consultant Paediatrician/Public Health Specialist

OUTLINE
General Consideration Intellectual Function Standardized Intelligent Test Adaptive Behaviour Definition of ID Epidemiology Early Warning Signs

OUTLINE
Classification Aetiology Clinical Assessment Investigation Management

INTELLIGENCE
Intelligence is genetically and Environmentally determined.
Discuss

What is intelligence?

Intellectual Function
Defined by standardized tests that measure the ability to reason in terms of Intelligence Quotient (IQ)
Mental Age Chronological Age x 100 Average intelligence: IQ of 100 (85 to 115).

IQ
IQ tests were created as an attempt to measure a person's abilities including: Language Numeracy Problem-solving

IQ
Factors like depression, language barriers and cultural differences can yield low IQ scores. Why?
Intelligence of a 15yrs old is indistinguishable from that of an adult

STANDARDISED INTELLIGENCE TESTS

Administered by qualified psychologists. Are subject to error and should support clinical findings.

STANDARDISED INTELLIGENCE TESTS

Bayley Scale for children under 2 years of age. Stanford-Binet test for ages 2-4 years.
Wechsler Preschool and Primary for ages 3yrs 10mo to 6yrs 7mo.

STANDARDISED INTELLIGENCE TESTS

Denver (Screening only). Gross assessment of developmental achievements for children up to 5 years.

ADAPTIVE BEHAVIOUR
Skills needed to live independently Daily living skills-getting dressed, using the bathroom, feeding oneself Communication skillsunderstanding what is said and being able to answer

ADAPTIVE BEHAVIOUR
Social skills with peers, family members, spouses, adults etc. Use of community resources Health & Safety

ADAPTIVE BEHAVIOUR Self-direction Job-related skills.

ADAPTIVE BEHAVIOUR
Assessment of adaptive behavior: Compare functional abilities of a child to those of similar ages living in the same environment

Structured interviews in communities

ID
Definition
A developmental disability that first appears in childhood or adolescence before the age of 18 and may persist throughout adulthood
A diagnosis of ID is made if an individual has an intellectual functioning level well below average as well as significant limitations in two or more adaptive skill areas.

Can you mention one adaptive behaviour?

What factors should be taken into consideration to make the diagnosis of ID?

EPIDEMIOLOGY
More common in males than in females. ID confers a social status that can be more handicapping than the specific disability itself. ID is a condition of both clinical and social importance.

EPIDEMIOLOGY
Symptoms of ID may not appear till later in childhood. Why?
Some cases of mild ID are not diagnosed before preschool.

EARLY WARNING SIGNS

May learn to sit up, crawl, walk later than other children. Learn to talk later. Difficulty in : Remembering things Understanding social rules

EARLY WARNING SIGNS

Difficulty in: Discerning cause and effect Logical thinking Solving problems Persistence of infantile behavior

DIAGNOSIS

Criteria for diagnosing ID: IQ score below 70 Significant limitations in TWO or more areas of Adaptive Behavior

Evidence that the limitations became apparent in childhood.

(Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)

CLASSIFIC ATION MILD ID (IQ 50-70)

Most are not identified before school. They are considered educable, and in many instances, are able to blend into society with minimal or no protective custody. They require some supervision and support, special educational and training facilities.

MILD ID(IQ 50-70) cont

Socially they are often immature and unsophisticated, with a poorly developed capacity for social interaction. Are usually free from gross physical defects, but with a higher than normal incidence of epilepsy.

MODERATE ID (IQ 35-50)

Are trainable Require protective custody. Have obvious motor or language delays. Given adequate support and training, mildly and moderately retarded adults can live with varying degrees of independence.

SEVERE AND PROFOUND ID

SEVERE ID:
The severely retarded child (IQ 35-20) Is trainable, but to a lesser degree PROFOUND ID: The profoundly retarded child (IQ < 20) Usually require continuous care. This group includes the most severely deformed, non-ambulatory, and minimally communicative.

AETIOLOGY
GENETIC CAUSES: Chromosomal abnormalities comprise the largest group of known genetic causes. The most common are the
Trisomies (Down syndrome) X-linked MR (Fragile-X syndrome)

DOWN SYNDROME
COMMONEST GENETIC CAUSE OF ID

FRAGILE-X SYNDROME
Next to Down syndrome. Males are affected more than females Clinical featuresprominent jaws and ears,large head, flat feet, seizures, scoliosis.

FRAGILE-X SYNDROME
Macro-orchidism Recurrent otitis media Refractive errors Mitral valve prolapse

GENETIC METABOLIC CAUSES

MPS PHENYLKETONURIA GALACTOSAEMIA TAY-SACHS ETC.

INTRAUTERINE CAUSES
Congenital malformations Complications of pregnancy Maternal malnutrition Drugs Radiations Congenital infections

DRUGS (ALCOHOL)
FOETAL ALCOHOL SYNDROME Microcephaly, Micrognathia, Smooth philtrum Thin smooth upper lip Cardiac defects Tremulous

PERINATAL CAUSES
PREMATURITY POSTMATURITY METABOLIC DISORDERS BIRTH INJURIES
HYPOXIC ISCHAEMIC ENCHEPHALOPATHY

POSTNATAL CAUSES
ENDOCRINOPATHIES METABOLIC DISORDERS TRAUMA INFECTIONS
MALNUTRITION

CULTURAL-FAMILIAL
Low Family Intelligence Low Socioeconomic Status Dysfunctional infant-caregiver interaction Family disorganisation Parental Psychopathology Parental substance abuse

CLINICAL ASSESSMENT
Developmental delay Evidence of genetic syndromes Serious family problems and neglect may be evident. Speech, language, motor, seizure disorders and behavior problems

INVESTIGATIONS
CHROMOSOMAL ANALYSIS X-RAYS CT SCAN EEG URINE AND BLOOD AMINO ACID AND ENZYME STUDIES

CAUTION!!
It is important to differentiate the deaf, blind, and the orthopaedically handicapped from the ID. This is often difficult since many ID children also have sensory and orthopaedic handicaps.

MANAGEMENT
Prevention
Accurate diagnosis provides prognosis and the foundation of genetic counseling A screening program for early detection of errors of metabolism Stimulation programs

MANAGEMENT cont.
Providing treatment of associated medical, emotional, and behavior problems. Protection against injuries.
Providing support and psychotherapy for the family.