Department of Psychiatric Nursing Care of Mentally Challenged Children
Presentation By T. Bhattarai, M.Sc. Department of Psychiatric Nursing, Batch-2009 19 th July, 2012, at 8:30 AM College of Nursing, BPKIHS 1 19th July, 2012 2 19th July, 2012 Content Introduction to Mental Retardation Classification Prevalence of MR Prevalence of other disorders and Problems among people with MR Effects of MR in Family Predisposing Factors Symptomatology Diagnosis Care of Children with MR Application of Nursing Process Summary References
3 19th July, 2012 Introduction In history- Use of term- Idiot, imbecile The term Mental Deficiency, Mental subnormality In UK- learning Disability In US- Intellectual Disability Mentally Challenged a synonymous term DSM IV and ICD 10 still have used the term Mental Retardation 4 19th July, 2012 Definition Is defined as Deficits in general intellectual functioning and adaptive functioning and measured by an individuals performance on intelligence quotient (IQ) tests. (APA, 2000)
Mental retardation is coded on Axis II in DSM-IV-TR Classification.
5 19th July, 2012 Classifications of Mental Retardation Mild (IQ of 5070) Moderate (IQ of 3549) Severe (IQ of 2034) Profound (IQ below 20)
6 19th July, 2012 Prevalence of Mental Retardation Range from 1 percent to 3 percent of the population Down syndrome in US- about 1 in every 700 births
Down syndrome accounts 10 % among all mentally retarded patients For a middle-aged mother (more than 32 years of age), the risk of having a child with Down syndrome with trisomy 21 is about 1 in 100 births, but when translocation is present, the risk is about 1 in 3.
7 19th July, 2012 The incidence of mental retardation is difficult to calculate because mild mental retardation sometimes goes unrecognized until middle childhood.
The highest incidence is in school-age children, with the peak at ages 10 to 14 years. 1.5 times more common among men than women
In older persons, prevalence is lower; those with severe or profound mental retardation have high mortality.
Profound mental retardation (IQ range below 20):- 1-2 %
Prevalence of mental retardation in Nepal is 5.9% (WHO, country health profile, Nepal).
9 19th July, 2012 Epidemiology of Physical Disorder The published rates of psychiatric disorder among people with MR vary widely (14.3% to 67.3%) People with severe disability (especially children)- only1/3 rd are continent. Ear infection and dental caries are common Epilepsy- 14-24 % of people with MR (5% in general population) A lifetime history of epilepsy 7-15% of people with mild to moderate MR, 45-67% with severe MR 50-82% of people with profound MR.
19th July, 2012 10 Prevalence of Psychiatric Disorder Previous view- mentally retarded didnt develop emotional disorders The causes are biological only Not true
But they experiences similar disturbances Symptoms might be modified Delusions, hallucinations and obsessions may not be easily recognized
19th July, 2012 11 The point prevalence of schizophrenia is 3 % among people with MR
rate of depressive disorders is same, but they are less likely to complain the mood changes
Mania has to be diagnosed mainly from over-activity, behavioural signs of excitement, irritability and nervousness.
Rate of suicide is comparatively rare
19th July, 2012 12 Anxiety disorder, phobic disorder are common but overlooked. PTSD after being victim of physixal or sexual abuse OCD more frequent than in general population Unusual dietary preferences and over eating are common, Pica is also more common Personality disorders are common, overlapped with behavioural disorders.
19th July, 2012 13 Development of delirium in response to infection, medication etc. is more common among this group. Alzheimers disease is more common
ADHD and autism both are more common.
Stereotypes, mannerism and rhythmic movement disorders (including head banging and rocking) occur in about 40% of children and 20% of adult with MR. 19th July, 2012 14 Challenging Behaviour Definition: Behaviour that is of intensity or frequency sufficient to impair the physical safety of the person with MR, to pose a danger to others or make difficult participation in the community.
10-20% of mentally retarded children and adolescents and 15% of the adults have some forms of challenging behaviour.
19th July, 2012 15 The causes of the challenging behaviour are: Pain and discomfort Understimulation Overstimulation Wish to escape an unpleasant situation Desire for attention or other rewards Frustration due to difficulty in communication Side-effects of the medication Psychiatric Disorder
19th July, 2012 16 When possible the primary cause should be treated, behavioural modification should be applied and where possible residential unit might be helpful for sometimes.
Forensic Problems People with mild MR have higher rates of criminal behaviour than the general population.
Impulsivity, suggestibility, vulnerability to exploitation and desire to please are often important reasons together with the influences in the social and family environment.
19th July, 2012 17 More likely to be detected and once apprehended, may be more likely to confess.
Common serious offenses- arson (fire rising) and sexual offences (usually exhibitionism)
Because of suggestibility- may give false confession Suggestibility can be assesses clinically, although a formal rating scale is available (Gudjonsson, 1992).
19th July, 2012 18 Sleep Disorder: Serious sleep problems such as obstructed sleep apnoea, excessive daytime sleepiness and parasomnias
19th July, 2012 19 Sexual Relationship and Parenthood: Develop sexual interest in the same way as other people
Sexual expressions of them are usually discouraged by parents and carers, and sexual feelings may not even be discussed. In past, sexual activity was discouraged Reason fear of producing further retarded children, It is now understood that many kinds of severe learning disability are not inherited.
19th July, 2012 20 Another concern they can not become a good parent.
These issues should be considered - contraception should be provided where appropriate.
Some people with MR have child like curiosity about other peoples bodies, which can be misunderstood as sexual.
19th July, 2012 21 Effects of Mental Retardation on the Family
When a newborn child is found to be disabled, the parents are inevitably distressed, the feelings of rejection are common, but seldom last long and are replaced by feeling of the loss of the hope.
They often experiences prolonged depression, guilt, shame or anger and have difficulty in coping with may practical problems. They too grieve for the intact child they had hoped and planned for.
19th July, 2012 22 A few reject the children and some become over involved in their care sacrificing other important aspects of the family.
It seemed likely that the siblings were often at some disadvantage because of the time and effort that had to be devoted to the disabled child.
As the parents grow older, many fear for the future of their now adult- disabled son or daughter. 19th July, 2012 23 Predisposing Factors for Mental Retardation Physiological Inborn error of metabolism Chromosomal Perinatal Causes Childhood illness, poisoning and trauma, nutrition 19th July, 2012 24 Predisposing Factors for Mental Retardation contd Psychosocial Understimulation Consequences of severe mental disorder 19th July, 2012 25 Specific Causes of Mental Retardation
Down Syndrome: The most common cause of MR. Affects approximately 1 in 1000 live births. The incidence rises with advancing maternal age at the time of conception 1529 years, 1 in 1500 3034 years, 1 in 800 3539 years, 1 in 270 4044 years, 1 in 100; over 45 years, 1 in 50
19th July, 2012 26 Causes of Down Syndrome 94 %are caused by trisomy 21, 3.5 % by translocation, 2.5 % by mosaicism. The cause of trisomy 21 is not known, but the general likelihood of recurrence is 1 %. 19th July, 2012 27 Fetal alcohol syndrome First reported as a syndrome in 1973 mental retardation with an incidence of 0.2 to 3 per 1000 live births. It has been estimated that between 10 and 20 % of mild mental retardation (IQ 5080) cases are caused by maternal alcohol use (eight or more drinks / day). 19th July, 2012 28 Specific Causes of Mental Retardation Contd..
Rett syndrome: First described by Andreas Rett in 1966, this syndrome of unknown aetiology affects exclusively girls, because male fetuses tend to die in the womb. Incidence varies between 1 in 10 000 and 1 in 15 000 females. The degree of mental retardation is usually severe or profound. 19th July, 2012 29 Phenylketonuria: Caused by an inborn error of amino acid metabolism which affects approximately 1 in 12 000 people. This metabolic disorder is caused by a deficiency of the hepatic enzyme, phenylalanine hydroxylase, which causes hyperphenylalaninaemia and phenylketonuria. inherited in an autosomal recessive manner Causes severe mental retardation if it remains untreated Features: fair hair, fair skin, and blue eyes because of the lack of the skin pigment precursor tyrosine
19th July, 2012 30 Symptomatology Developmental Characteristics of Mentally Retarded Persons Profound Preschool Age (0 to 5 yrs) Maturation and Development School Age (6 to 20 yrs) Training and Education Adult (21 yrs and Above) Social and Vocational Adequacy Gross retardation; minimal capacity for functioning in sensorimotor areas; needs nursing care; constant aid and supervision required Some motor development present; may respond to minimal or limited training in self-help Some motor and speech development; may achieve very limited self- care; needs nursing care 19th July, 2012 31 Preschool Age (0 to 5) Maturation and Development School Age (6 to 20) Training and Education Adult (21 and Above) Social and Vocational Adequacy Poor motor development; speech minimal; generally unable to profit from training in self- help; little or no communication skills Can talk or learn to communicate; can be trained in elemental health habits; profits from systematic habit training; unable to profit from vocational training May contribute partially to self-maintenance under complete supervision; can develop self-protection skills to a minimal useful level in controlled environment 19th July, 2012 32 Severe MR Moderate MR Preschool Age (0 to 5 yrs) Maturation and Development School Age (6 to 20 yrs) Training and Education Adult (21 yrs and Above) Social and Vocational Adequacy Can talk or learn to communicate; poor social awareness; fair motor development; profits from training in self-help; can be managed with moderate supervision Can profit from training in social and occupational skills; unlikely to progress beyond second-grade level in academic subjects; may learn to travel alone in familiar places May achieve self- maintenance in unskilled or semiskilled work under sheltered conditions; needs supervision and guidance when under mild social or economic stress 19th July, 2012 33 Mild MR Preschool Age (0 to 5 yrs) Maturation and Development School Age (6 to 20 yrs) Training and Education Adult (21 yrs and Above) Social and Vocational Adequacy Can develop social and communication skills; minimal retardation in sensorimotor areas; often not distinguished from normal until later age Can learn academic skills up to approximately sixth-grade level by late teens; can be guided toward social conformity Can usually achieve social and vocational skills adequate to minimal self- support, but may need guidance and assistance when under unusual social or economic stress 19th July, 2012 34 Diagnosis Diagnostic Criteria According to DSM IV A. Significantly subaverage intellectual functioning: an IQ of approximately 70 or below on an individually administered IQ test (for infants, a clinical judgment of significantly subaverage intellectual functioning). B. Concurrent deficits or impairments in present adaptive functioning (i.e.. the person's effectiveness in meeting the standards expected for his or her age by his or her cultural group) in at least two of the following areas: communication. self-care, home living, social/interpersonal skills, use of community resources, self-direction, functional academic skills, work, leisure, health, and safety. C. The onset is before age 18 years.
19th July, 2012 35 History Taking Family history of inherited disorder Abnormality in the pregnancy and delivery of child Developmental History Full account of behavioural disorder Account of associated medical conditions like congenital heart disease, epilepsy, cerebral palsy etc.
19th July, 2012 36 Physical Examination Systemic physical examination including recording of head circumference Other symptoms suggestive of specific syndromes like Down syndrome, fetal alcohol syndrome etc. Neurological examination with attention to vision and hearing testing
19th July, 2012 37 Mental Status Examination The approach should be flexible, they attend and concentrate poorly. Need to be carried out informally and intermittently. Previous base line intelligence level should be assessed.
19th July, 2012 38 Developmental Assessment Standardized assessment instruments Vinland Social Maturity Scale (VSMS) for children who do not cooperate in testing, it can be completed by interview with a reliable informant. Wechsler Adult Intelligence Scale (WAIS)
Functional Behavioural Assessment Antecedent, behaviour and Consequences Analysis
Assessment of Social Interaction and Behaviour Assessment of interaction of person with MR with a person closely related to his/her care 19th July, 2012 39 Care of Children with Mental Retardation Principle of normalization An idea developed by Scandinavia in the 1960s This term refers to the general approach of providing a pattern of life style as near normal as possible. It implies that all people with MR will live in the community, participating in normal activities and relationships, making choices and having full social opportunities. Children are brought up whenever possible with their families, and adults are encouraged to live as independently as possible.
19th July, 2012 40 People with MR should be integrated into society Deinstitutionalization in US
For the few who need special social and health care, accommodation and activities are designed to be as closes as possible to those of family life.
19th July, 2012 41 General Provisions: Identification of population with the problem in the community is crucial before planning the care. Individual assessment of those identified as individual need may be different. General approach to the care is educational and psychosocial. Family physician and paediatrician are responsible for the early detection of MR. The team providing continuing care includes psychologist, speech therapists, nurses, occupational therapists and physiotherapist in addition to a psychiatrist.
19th July, 2012 42 Preventive Services In developed countries- Focused on reduction of genetic causes of MR.
In developing countries- Focused on general measures to improve the health of mothers during pregnancy and by better perinatal care 19th July, 2012 43 Genetic Screening and Counselling: Begins with the assessment of the risk that an abnormal child will be born. Risks of screening are explained to the parents
A positive diagnosis of an abnormality leading to termination / a false positive screening causes considerable distress. Those involved in screening should be alert to psychological issues and have the appropriate counseling skills.
19th July, 2012 44 Prenatal Care: Begins even before conception, with immunization against rubella for girls who lacks immunity, and advice on diet, smoking and alcohol. Prenatal diagnosis overlaps with genetic screening. Amniocentesis, fetoscopy, and ultrasound scanning of the fetus in second trimester can reveal chromosomal abnormalities, neural tube defects, and about 60% of inborn error of metabolism. 19th July, 2012 45 Rhesus Incompatibility: It is now largely preventable by giving anti D antibody.
For pregnant women with diabetes mellitus, special care may change the outlook of the fetus.
19th July, 2012 46 Postnatal Prevention: In developed countries like UK, all the infants are routinely tested for phenyleketonuria/ hypothyroidism / galactosaemia Lead level detection Intensive care unit and improved methods of treatment for premature and low birth weight
19th July, 2012 47 Compensatory Education: Compensatory education is intended to provide the optimal conditions for the mental development of the child with mental retardation.
19th July, 2012 48 Help for Families From the time that the diagnosis is first time made. Not enough to give the worried parents a full explanation on just one occasion. Paediatricians and health visitors are usually involved in this process.
19th July, 2012 49 Parents need continuing support, When the child starts school They should be helped with practical matters Day care for child during school holidays The parents need continual psychological support
Likely to need extra help when child is approaching puberty leaving school Making the transition from child to adult services is often extremely stressful.
19th July, 2012 50 Education, Training and Occupation Early start of education- should attend a play group or nursery class the least disabled children can attend the remedial classes in ordinary schools.
Education in an ordinary school offers both advantages and disadvantages.
19th July, 2012 51 Before the children leave the school, they need reassessment and vocational care guidance. Most young people with mild learning disability are able to take normal job or enter sheltered employment. Adult with severe disability are likely to transfer to adult day centres 19th July, 2012 52 Residential Care Home care is emphasized
If burden of care is high residential group home.
19th July, 2012 53 Medical Services: Should have the equal access to general and specialist medical services as other citizens, but they require extra support.
Psychiatric Services: Psychiatric care is an essential part of comprehensive community service for people with learning disability. 19th July, 2012 54
Treatment of Psychiatric Disorders and Behavioural Problems
Medication: Ongoing assessment and physical assessment is required, as they may have decrease communication ability to describe the adverse effects May develop adverse effects at lower doses and suffer from over sedation, delirium and extra pyramidal effects Special precaution while selecting the drugs, as older antiepileptics are found to have effect of emotional blunting and decrease of cognitive functions.
19th July, 2012 55 Psychological Treatment Psychotherapy- simple discussion if often helpful. Cognitive therapy with patients with more verbal output. Counselling for the parents is the important part of treatment.. For children with profound mental retardation - the use of play and sensory stimulation
19th July, 2012 56 Behavioural Modifications Behavioural methods are potentially helpful. Can be taught basic skills like washing, toilet training, dressing Parents and teachers are trained to train their children. Undesired behaviour- ABC Aggressive behaviours - time out. Modeling, shaping etc are the some of the technique of bring positive behavioural changes.
19th July, 2012 57 Special Problems Growing Old: The care may become increasingly burdensome as parents grow older. Parents are often concerned with the future of their child are still reluctant to arrange the alternative care while they are still alive.
19th July, 2012 58 Exploitation and Abuse: ..are vulnerable for the exploitation and to physical and sexual abuse. In the past, these problems were associated with the poorly managed large institutions, but they can occur also in small community units. Such units needs regular supervision, and clinicians should consider abuse as an uncommon but important cause of disturbed behaviour.
19th July, 2012 59 Ethical and Legal Problems The policy of normalization - can create the conflict of interest between the interest of learning disabled and that of other people (eg. parents , colleagues, siblings of them). In secondary school, the children with special needs were founds to be bullied 3 times more than other ordinary counterparts.
Consent to Treatment- Many people with mental retardation are unable to give informed consent for physical and psychiatric treatment.
Consent to Research
19th July, 2012 60 19th July, 2012 61 Nursing Assessment: Same as medical Assessment as described earlier.
Common Nursing Diagnoses Risk for injury Self-care deficit Impaired verbal communication Impaired social interaction
19th July, 2012 62 Nursing Interventions: Dx. Risk for Injury 1. To ensure client safety: Create a safe environment for the client. Remove small items from the area where the client will be ambulating and move sharp items out of his or her reach. Store items that client uses frequently within easy reach. Pad side rails and headboard of client with history of seizures. Prevent physical aggression and acting out behaviors by learning to recognize signs that client is becoming agitated.
19th July, 2012 63 DX. Self Care Deficit Identify aspects of self-care that may be within the clients capabilities. Work on one aspect of self-care at a time. Provide simple, concrete explanations. Offer positive feedback for efforts at assisting with own self-care. When one aspect of self-care has been mastered to the best of the clients ability, move on to another. Encourage independence but intervene when client is unable to perform. 19th July, 2012 64 Dx. Impaired Verbal Communication Maintain consistency of staff assignment over time. Anticipate and fulfill clients needs until satisfactory communication patterns are established. Learn (from family, if possible) special words client uses that are different from the norm. Identify nonverbal gestures or signals that client may use to convey needs if verbal communication is absent. Practice these communication skills repeatedly. 19th July, 2012 65 Impaired Social Interaction Remain with client during initial interactions with others. Explain to other clients the meaning of some of the clients nonverbal gestures and signals. Use simple language to explain to client which behaviors are acceptable and which are not. Establish a procedure for behavior modification that offers rewards for appropriate behaviors and
Renders an aversive reinforcement in response to the use of inappropriate behaviors.
19th July, 2012 66 Evaluation/ Outcome Criteria Client has experienced no physical harm. Client assists with self-care activities to the best of his or her ability. Client is able to communicate with consistent caregiver. Client interacts with others in a socially appropriate manner.
19th July, 2012 67 Summary People with mental retardation have deficits in intellectual and adaptive functioning ranging from mild to profound. Certain physical, behavioural and psychiatric problems are more common in this group together with that they are vulnerable to bear ethical and legal complication. Prevention of MR can be done by genetic screening and counselling, prenatal, perinatal and post natal care 19th July, 2012 68 Child with MR should be helped in education, training and occupation.
Family requires support, respite and guidance while caring their loved one with MR. 19th July, 2012 69 19th July, 2012 70 References 1. Campbell M, Malone RP. Mental retardation and psychiatric disorders. Hosp Community Psychiatry. 1991 Apr;42(4):374-9. 2. Sadock B.J. Sadock V.A. Kaplan and Saddocks Synopsis of Psychiatry., Wolters Kluwer/Lippincott Williams and Wilkins, Philadelphia 2007 3. Gelder, Michael G., Lopez-Ibor, Juan J., and Andreasen, New Oxford Textbook of Psychiatry,volume 1, Oxford University press, New York, first published in 2000, 956-957. 4. Townsend M.C. Nursing Diagnosis in Psychiatric Nurising. Philadelphia, FA Davis Company. Seventh Edition; 2008
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