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mental retardation


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mental retardation

  2. 2. INTRODUCTION • Mental retardation is one of most common chronic neurologic disabiity of childhood. • MR affects about 1-3% of population. • Majority of cases are idiopathic. • Most common mild MR(75-90%) often goes unrecognised. • More common in lower socio-economic groups.
  3. 3. DSM IV – TR Definition  Significantly below average intellectual functioning: IQ of below 70 on an individually administered IQ test.  Accompanied by significant limitations in adaptive functioning in at least 2 skill areas: Communication, self-care, home living, social/interpersonal skills, use of community resources, self-direction, functional academic skills, work & leisure, health and safety.  Onset before age 18yr.
  4. 4. Signs & Symptoms • Delay in language development. • Find it hard to remember things. • Difficulty in learning social rules. • Have trouble learn specific subject • Have trouble solving problems • Lack of social inhibitors. • Lack of self care skills. • Persistence of infantile behaviour . • Unable to take higher education.
  5. 5. Grades of MR : According to IQ : • Borderline intellectual functioning70--84 • Mild mental retardation 50–69 • Moderate mental retardation 35–49 • Severe mental retardation 20–34 • Profound mental retardation Below 20
  6. 6. Mild MR • May not be obvious in early childhood, untill they go to school. • In School - have poor academic performance (difficult to differentiate from learning disability or emotional & behavioral disorder.) • can learn reading & mathematical skills to level of a typical 9-12 yr child. • Learn self care &practical skills to live independently & earn for them self.
  7. 7. Moderate MR • obvious within 1st year of life • Problem with social work • Behaviourable age -8 yrs • Academic skills – 2nd grade level • will face difficulty in school, at home, and in the community • Need special school, but they can still progress to become functioning members of society. As adults they may live with their parents, in a supportive group home.
  8. 8. Severe & Profound MR • Little or no speech • Limited abilities to manage self care. • Require high supervision . • Behaviourable age – 3 yrs. • They may learn some daily activities but will require full time care –taker.
  9. 9. ASSOCIATED PROBLEMS • Self injury • Pica • CP • Epilepsy • Toilet probs • Sleep disorders • Eating problems • Poisoning • Sexual abuse • Learning disorders • Behavior problems
  10. 10. Developmental assesment • Denver Development Screening Test-II • Bayley Scales of Infant Development • BARODA PHATAK DST • Trivendrum Developmental Screening Chart Test for intelligence • Binet kamat test • Weschler’s intelligence scale for children • Goodenough draw a man test.
  11. 11. Denver II Developmental Screening Test • Most widely used test for quick routine screening, for children upto 6yrs. Assesses child development in all four domains (gross motor , fine motor adaptive, language, personal social behavior),taking 10-30 min. • The milestones are shown in a graphical manner & items through which the chronological age passes are tested.
  12. 12. BAYLEY SCALE OF INFANT DEVELOPMENT • Based on motor scale , mental scale and infant behaviour • Up to 30 months of age • Takes 30-60 minutes • 67 motor scale ,107 mental scales BARODA DEVELOPMENT SCREENING TEST • Based on BSID, developed by Dr. phatak according to baroda norms, suitable for Indian children. • Does not require standard equipment, domains evaluated are gross motor ,fine motor, cognitive, takes 10 min.
  13. 13. Wechsler Intelligence Scale for children • for children from 5-15yrs – Mean score of 100 with standard deviation of 15 – Gives verbal and performance scores, takes 45-60 min. – Broken into 12 subtests 6 each for verbal & performance abilities. • MALIN INTELLIGENCE SCALE FOR INDIAN CHILDREN: - Indian adaptation of WISC - It may not give real capabilities in non school going children as mostly influenced by formal schooling system
  14. 14. STANFORD BINET INTELLIGENCE SCALE • for children>2yr. • Include verbal ability ,perceptual skills , short term memory & hand and eye co-ordination • takes 45-60 minutes • BINET – KAMAT TEST -indian adaptation of stanford - binet scale - also available in hindi
  15. 15. Goodenough harris ‘draw a man test’
  16. 16. APPROACH TO A CHILD WITH MR • Detailed development history. • Antenatal history. • Perinatal history. • Any neurological problem: seizure, spasticity, motor deficit, abnormal movements, vision& hearing. • Features s/o of IEM: abdominal distension. • F/o of hypothyroidism. • Past history of febrile encephalopathy.
  17. 17. Cont.. • Emotional deprivation. • Level of indipendence. • Scholastic performance. • Consangiunity. • Sibling history. • H/o temper tantrums, hyperkinesis, self destructive behaviour. • Any h/o physical & psychological abuse. • Lead exposure.
  18. 18. Physical examination • Anthropometry : OFC, shape, frontanelle sutures, monitor OFC. • Dysmorphic features: f/o MPS,f/o down’s syndrome, fragileXsyndrome, • Neurocutaneous disorder. • Detailed neurological examiation: tone, power, primitive reflexes, symmetry. • Assesment of hearing & vision.
  19. 19. Investigations • Individualised approach • Vision & hearing assesment • R/o hypothyroidism. • Cytogenetic study: high resolution g banding karyogram screening for numeric& structural anomalies, • FISH analysis for subtelomeric rearrangement. • Neuroimaging: MRI & CT scan. • IEM EVAUATION:24 hr urinary screening for aminoacids, organic acids, GAGs, pl.aminoacids, Enzymatic study in fibroblasts & lymphoblasts. • EEG • Xray • Fragile X syndrome screening
  20. 20. Management Treatable /Preventable causes of MR • Hypothyroidism • Severe PEM • Perinatal asphyxia • Preterm /LBW • Meningitis, encephalitis • Bilirubin encephalopathy • IEM: Galactosemia ,PKU
  21. 21. Prevention • Primary prevention: improvement in perinatal care, iodistion of salt,immunisations,detection &care of high risk pregnancies, penatal screening &genetic counselling. • 2nd ary prevention: neonatal screening, screening of “high risk babies” & early intervention measures. • Tertiary prevention: stimulation, training,& education, vocational oppertunities. • Mainstreaming • Support for families • Parenteral support groups.
  22. 22. Drug Therapies • No specific drugs but some symptoms can be controlled. • Neuroleptic drugs to reduce aggressive and antisocial behavior (phenothiazines). • antipsychotic drugs( risperidone). • Antidepressant drugs can improve sleep, possibly help reduce self-injurious behavior, reduce depression.
  23. 23. TAKE HOME MASSAGE • Mental retardation is preventable in some cases. • Most cases are idiopathic & are mild. • Diagnosis is clinical. • Examination for dysmorphology & detailed neurology is of essence. • Care rather than cure is the way of management in most of the cases.
  24. 24. GROSS MOTOR: 180 degree flip examination in infant < 8 months and gait for > 1 year • Supine: Note posture, abnormal ATNR, involuntary movements with CP. paucity of movements for hemiplegia. • Pull to sit: head lag. Sitting: Head and trunk control. Back is straight or rounded. • Weight bearing: scissoring, hypotonia, advanced weight bearing (CP) • Ventral suspension: Describe posture, low tone, increase extensor tone. • Prone: Observe ability to raise head, trunk above horizontal,
  25. 25. Primitive reflexes: 1. Sucking/Rooting :( 0-4,6mths), 2. Palmer grasp; (0-3 months). 3. Placing, stepping: (0-6weeks) 4. ATNR: 2-6 Months. 5. Landau: on ventral suspension, normally extend head, trunk, and hip. Flex head and neck, response is flexion of hip, trunk.0-6 month). 6. Neck righting reflex: rotation of trunk 6mths-2 years. 7. Moro: 0-4 months. 8. Parachute: 6-12 months persist. Prone position, move rapidly, face down. Will extend both upper limbs.