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Intellectual disability


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intellectual disability ( mental retardation)

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Intellectual disability

  1. 1. Dr. Lamiaa Gamal Assistant lecturer of child health, Kindergarten Faculty
  2. 2. •a group of disorders that have in common deficits of adaptive and intellectual function and an age of onset before maturity is reached.
  3. 3. Country and/or language Term United States Intellectual disability Australia Intellectual disability Canada (English, French) Mental deficiency, intellectual handicap England Learning disability*, intellectual disability, developmental disability• France Mental deficiency, mental apraxia Germany Mental handicap, mental retardation Italy Mental delay, mentally deficient Estonia Mental retardation Puerto Rico Mentally slowed down Spain Mental delay
  4. 4. DSM-5
  5. 5. Global Developmental Delay • Diagnosed reserved for individuals under 5 when clinical severity level cannot be reliably assessed. • Diagnosed when an individual fails to meet expected developmental milestones in several areas of intellectual functioning, and applies to individuals who are unable to undergo systematic assessments of intellectual functioning, including children who are too young to participate in standardized testing. • Requires reassessment after a period of time.
  6. 6. Unspecified Intellectual Disability • Diagnosed in individuals over 5 when assessment of the degree of intellectual disability by means of locally available procedures is difficult or impossible because of: - associated sensory or physical impairments, as in blindness or prelingual deafness; locomotor disability; or - presence of severe problem behaviors or co-occurring mental disorder. - Should only be used in exceptional circumstances and requires reassessment after a period of time.
  7. 7. ICD 11 • ICD-11 uses the term intellectual developmental disorders to indicate that these are disorders that involve impaired brain functioning early in life. These disorders are described in ICD-11 as a meta syndrome occurring in the developmental period analogous to dementia or neurocognitive disorder in later life. • There are four subtypes in ICD-11: mild, moderate, severe, and profound.
  8. 8. Intellectual disability has an overall general population prevalence of approximately 1%, and prevalence rates vary by age Prevalence for severe intellectual disability is approximately 6 per 1,000 males are more likely than females to be diagnosed with both mild MR (average male: female ratio 1.6:1) and severe MR (average male: female ratio 1.2:1)
  9. 9. Country (Reference) Source of study population Definition used Total study population Prevalence per 1000 population Australia (Beange & Taplin 1996) Administrative data on 20-50 year olds AAMR classification of 1983 104584 3.3 Male = 3.4 Female = 3.2 Australia (Leonard et al. 2003) Administrative data on children 6-15 years DSM-IV TR 240358 14.3 Canada (Bradley et al. 2002) Administrative data and population based study on 14- 20 year old adolescents ICD 10 35485 7.2 China (Zuo et al. 1986) Survey of 0-14 year old childrenAAMR definition 7150 7.8 Male = 7.8 Female = 7.9 China (Xie et al. 2008) Household survey of children aged 0-6 years Specific disability criteria 60124 9.3 Male = 10.1 Female = 8.3 Ethiopia (Fitaw et al. 2006) Population based study on adults ICF 24453 3.9 Finland (Rantakallio et al. 1986) Administrative data on specific birth cohort of children ICD 9 12058 5.6 (Mild mental retardation) 6.3 (Moderate-severe mental retardation) Ireland (including Northern Ireland, UK) (McConkey et al. 2006) Administrative data of adults ICD 10 3961701 6.3 Norway (Stromme et al. 1998) Administrative data on specific birth cohort of children DSM-IV 30037 6.2 Male = 8.4 Female = 5.7 USA Administrative data on 10 year DSM-III 89534 12 Male = 13.8
  10. 10. Prenatal Genetic syndromes Environmental influences maternal disease Inborn errors of metabolism Perinatal delivery-related events Postnatal infections traumatic brain injury Severe and chronic social deprivation Toxic metabolic syndromes and intoxications
  11. 11.  Mild MR – 55-70 IQ – Adaptive limitations in 2 or more domains  Moderate MR – 35-54 IQ – Adaptive limitations in 2 or more domains  Severe MR – 20-34 IQ – Adaptive limitations in all domains  Profound MR – Below 20 IQ – Adaptive limitations in all domains
  12. 12. Conceptual Skills: communication, functional academics, self- direction, money concepts Social Skills: interpersonal skills, self-esteem, naiveté/gullibility, self-governance (obeys rules) Practical Skills: self-care, domestic skills, work, health & safety
  13. 13. Severity mental age as adult Adult adaptation Mild 9-11 yr Reads at 4th-5th grade level; simple multiplication and division; writes simple letter, lists; completes job application; basic independent job skills (arrive on time, stay at task, interact with coworkers); uses public transportation, might qualify for driver's license; keeps house, cooks using recipes Moderate 6-8 yr Sight-word reading; copies information, e.g., address from card to job application; matches written number to number of items; recognizes time on clock; communicates; some independence in self-care; housekeeping with supervision or cue cards; meal preparation, can follow picture recipe cards; job skills learned with much repetition; uses public transportation with some supervision Sever 3-5 yr Needs continuous support and supervision; might communicate wants and needs, sometimes with augmentative communication techniques Profound <3 yr Limitations of self-care, continence, communication, and mobility; might need complete custodial or nursing care International Statistical Classification of Diseases and Related Health Problems, 10th edition (World Health Organization).
  14. 14. Co-occurring mental, neurodevelopmental, medical, and physical conditions are frequent in intellectual disability, with rates of some conditions (e.g., mental disorders, cerebral palsy, and epilepsy) three to four times higher than in the general population.
  15. 15. The most common co-occurring mental and neurodevelopmental disorders are: - attention-deficit/hyperactivity disorder - depressive and bipolar disorders - anxiety disorders - autism spectrum disorder - stereotypic movement disorder (with or without self-injurious behavior) - impulse-control disorders - major neurocognitive disorder
  16. 16. • Different studies in the review showed that among children with mental retardation, autism is present in about 25%, ADHD in about 10%, and cerebral palsy in 7-30%, depending on the severity of mental retardation. • Among adults with Down's Syndrome, dementia is the most common cause of mortality and morbidity, and research from The Netherlands has found that often it has an earlier age of onset (8.9% in 45-49 year old age-group) compared to the general population
  17. 17. • Dysmorphic syndromes, (multiple congenital anomalies), microcephaly • Major organ system dysfunction (e.g., feeding and breathing) Newborn • Failure to interact with the environment • Concerns about vision and hearing impairmentsEarly infancy (2-4 mo) • Gross motor delay Later infancy (6-18 mo) • Language delays or difficulties Toddlers (2-3 yr) • Language difficulties or delays • Behavior difficulties, including play • Delays in fine motor skills: cutting, coloring, drawing Preschool (3-5 yr) • Academic underachievement • Behavior difficulties (attention, anxiety, mood, conduct, etc.) School age (>5 yr)
  18. 18. Associated Features Supporting Diagnosis: • Difficulties with social judgment; assessment of risk; self- management of behavior, emotions, or interpersonal relationships; or motivation in school or work environments. • Lack of communication skills ….. disruptive and aggressive behaviors. • Gullibility and lack of awareness of risk may result in exploitation by others and possible victimization, fraud, unintentional criminal involvement, false confessions, and risk for physical and sexual abuse. • Individuals with a diagnosis of intellectual disability with co-occurring mental disorders are at risk for suicide. Thus, screening for suicidal thoughts is essential in the assessment process. • Because of a lack of awareness of risk and danger, accidental injury rates may be increased.
  19. 19. • A comprehensive evaluation includes - An assessment of intellectual capacity and adaptive functioning. - Identification of genetic and non-genetic etiologies. - Evaluation for associated medical conditions (e.g., cerebral palsy, seizure disorder). - Evaluation for co-occurring mental, emotional, and behavioral disorders.
  20. 20. Cognitive Ability Assessment: WISC Series (WISC IV; WAIS II; WPPSI, etc.) Stanford-Binet V Woodcock-Johnson Test of Cognitive Abilities Bayley Scales of Infant Development Kaufman Assessment Battery for Children
  21. 21. Adaptive Behavior Assessment  Vineland II Adaptive Behavior Scales (Sparrow, Cicchetti, & Balla, 2005)  Scales of Independent Behavior– Revised (SIB-R) (Brunininks, Woodcock, Weatherman, & Hill, 1996)  Adaptive Behavior Assessment System 2nd Edition (ABAS – II) (Harrison & Oakland, 2003)
  22. 22.  Basic pre- and perinatal medical history  Three-generational family pedigree  Physical examination  Genetic evaluation (e.g., karyotype or chromosomal microarray analysis and testing for specific genetic syndromes)  Metabolic screening  Neuroimaging assessment
  23. 23.  In many countries of the MENA region disabled children are facing: health, educational, social and psychological problems. For example, disabled children are facing low enrolment ratios, limited health care and low health awareness among families of disabled children.  Some disabled children in MENA region face problems of stigmatization, social exclusion and isolation, thus they become deprived of active participation in social, economic and community life.
  24. 24. The 2000 Demographic and Health Survey in Egypt has estimated the total number of children in need of special education at 600,000. However, according to Ministry of Education, only 15% of them receive education in regular schools. Girls are even more disadvantaged than boys. The low level of enrolment is partially due to the unavailability of appropriate education and partially to the fact that some parents do not send their disable children to schools. Some families believe that disabled children are not capable of receiving education.
  25. 25. - Many countries in the MENA region have insufficient health facilities and poor training for medical personnel working with disabled children. - The lack of community education programs leave many undetected child disabilities. - Many communities, especially in rural areas, lack rehabilitative services for disabled children
  26. 26. Because of the stigma associated with intellectual disability, they may use euphemisms to avoid being thought of as “stupid” or “retarded” and refer to themselves as learning disabled, dyslexic, language disordered, or slow learners. Some people with intellectual disability emulate their social milieu to be accepted. They may be social chameleons and assume the morals of the group to which they are attached. Some would rather be thought “bad” than “incompetent.”
  27. 27. Some disabled children in countries of MENA region are also vulnerable to: maltreatment and humiliation particularly those living in rehabilitative care institutions where emotional, physical and sometimes even sexual abuses are not uncommon
  28. 28. Challenging behaviors (aggression, self-injury, oppositional defiant behavior) and mental illness (mood and anxiety disorders) occur with greater frequency in this population than among children with typical intelligence. These behavioral and emotional disorders are the primary cause for out-of-home placements, reduced employment prospects, and decreased opportunities for social integration
  29. 29. In many countries of the MENA region these laws and decrees have neglected issues related to  prevention  early detection  community based rehabilitation (CBR)  information and registration  issues concerning cooperation and integration between governmental agencies, NGO’s and international organizations working in the field of child disability
  30. 30. Immunization programs Health education Prevention of trauma and injuries Effective antenatal/ natal care Genetic counselling Prevention of poisoning and drug abuse
  31. 31. Pre symptomatic detection of certain disorders lead surveillance dietary restriction in metabolic diseases thyroid hormone replacement Treatment of associated conditions including vision and hearing impairment, seizures, and other co-morbid medical disorders
  32. 32. Access to and provision of appropriate comprehensive services and resources Early detection of complications Treatment of comorbid conditions Prevention and treatment of psychosocial disorders
  33. 33.  phenylketonuria………newborn screening, dietary treatment  Galactosemia …………newborn screening, dietary treatment  Congenital hypothyroidism…….. newborn screening and thyroid hormone replacement therapy  use of anti-Rh immune globulin to prevent Rh disease and severe jaundice in newborn infants  Hib diseases by using the Hib vaccine  measles encephalitis ………… measles vaccine  German measles during pregnancy………. Rubella vaccine  Fetal alcohol syndrome
  34. 34. Early intervention programs Special education services ( individualized educational programs) Family support services (Counseling, Training, Home visitation, Social services) Pharmacotherapy Health services, including hearing and vision Nutrition counseling Assistive technology (which may include tape-recorded texts, reading scanners, or voice-activated computer programs) Medical diagnostic services Transportation and other assistive technology
  35. 35. For children with an intellectual disability, primary care has a number of important components: - Provision of the same primary care received by all other children of similar chronological age - Anticipatory guidance relevant to the child's level of function: feeding, toileting, school, accident prevention, sexuality education - Assessment of issues that are relevant to that child's disorder: e.g., examination of the teeth in children who exhibit bruxism, thyroid function in children with Down syndrome, cardiac function in Williams syndrome
  36. 36. • Shapiro B., Batshaw M. intellectual disability. In: kliegman R. (eds.) Nelson Textbook of Pediatrics. 19th ed. USA: Elsevier; 2011. p505- 524 • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington. American psychiatric association; 2013 • El Deeb B.. National Report on Disability Statistics in Egypt 21-23 March 2005. Central Agency for Public Mobilization & Statistics (Egypt). • Pivaliza P., Miller G.. Intellectual disability (mental retardation) in children: Management; outcomes;and prevention. ce=HISTORY (accessed 14 March 2015). • Maulik P., Harbour C. Epidemiology of Intellectual Disability. ( accessed 21 March 2015) • Nour O. Child Disability in some countries of the MENA region: Magnitude, Characteristics, Problems and Attempts to alleviate Consequences of impairments. Paper Presented at the XXV th IUSSP International Population Conference, 2005.