Intellectual disability (Childhood disorder)

BEHAVIOURAL & EMOTIONAL
DISORDERS
OCCURING DURING
CHILDHOOD & ADOLOSCENCE
Nitika Bhatt, Assistant Professor, MHN Dept. HCN, SRHU

INTRODUCTION
• It has been estimated that approximately one-third of the childhood
suffering not from physical but primarily from psychological illness.
• Identification and handling of the emotional, behavioral and
developmental disorders problems of the childhood and adolescents is
very essential for any health care workers including nurses.

CONT…
• However, Disorders in which the symptoms usually first become
evident during infancy, childhood or adolescence does not mean that
they do not appear later in life or that symptoms associated with other
disorders such as major depression or schizophrenia.
• Any nurse working with children or adolescents should be
knowledgeable about “normal” stages of growth and development.

ICD 11 CLASSIFICATION OF BEHAVIOURAL
Intellectual
Disability
Autism ADHD
Eating
disorders
Learning
disorders
CLASSIFICATION OF BEHAVIOURAL AND EMOTIONAL
DISORDERS OCCURING DURING CHILDHOOD AND
ADOLESCENCE

ICD 11 CLASSIFICATION OF BEHAVIOURALAND EMOTIONAL DISORDERS OCCURING DURING CHILDHOOD AND
ADOLESCENCE/ NEURODEVELOPMENTAL DISORDERS
6A00: Disorders of intellectual development
6A01: Developmental speech or language disorders
6A02: Autism spectrum disorder
6A03: Developmental learning disorder
6A04: Developmental motor coordination disorder
6A05: Attention deficit hyperactivity disorder
6A06: Stereotyped movement disorder
6A0Y: Other specified neurodevelopmental disorders
6A0Z: Neurodevelopmental disorders, unspecified

INTELLECTUAL DISABILITY/
INTELLECTUAL DEVELOPMENTAL
DISORDER/ MENTAL RETARDATION/
MENTAL SUBNORMALITY

INTELLECTUAL DISABILITY
Intellectual disability is defined by deficits in general intellectual
functioning and adaptive functioning (APA, 1994).
• 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.

DEFINITION
Intellectual disability is defined as a “disorder with onset during the developmental
period that includes both intellectual and adaptive functioning deficits in
conceptual, social and practical domains.
1. Conceptual – language, reading, writing, math, reasoning, knowledge, memory.
2. Social – empathy, social judgment, communication skills, the ability to follow
rules and the ability to make and keep friendships.
3. Practical – independence in areas such as personal care, job responsibilities,
managing money, recreation and organizing school and work tasks.
American Psychiatric Association [APA], 2013

EPIDEMIOLOGY
Age The age and characteristics of onset depend on the cause of the
disability and the severity
Gender Males are more likely than females to be diagnosed with ID
Ethnicity Black children are more likely to be diagnosed with ID as compared
to white children.
Socioeconomic status Poverty is one of the most consistent risk factors for ID.
Twice in low socioeconomic status children.

ETIOLOGICAL IMPLICATIONS
In approximately 30 to 40 percent of individuals seen in clinical settings
the etiology cannot be determined. Five major predisposing factors have
been identified:
HEREDITY
FACTORS
EARLY
ALTERATIONS IN
EMBRYONIC
DEVELOPMENT
PREGNANCY
AND
PERINATAL
FACTORS
GENERAL MEDICAL
CONDITIONS ACQUIRED
IN INFANCY OR
CHILDHOOD
ENVIRONMENTAL
INFLUENCES AND
OTHER MENTAL
DISORDERS

1. HEREDITY FACTORS
Heredity factors are implicated as the cause in approximately 5 percent of the cases.
• These factors include inborn errors of metabolism, such as phenylketonuria and
hyperglycinemia.
• Also include are chromosomal disorders such as Down’s syndrome.

Down Syndrome:
It is caused due to trisomy 21, i.e. person have 47 chromosomes, with an extra
chromosome 21.
• Intellectual disability is the overriding feature of Down syndrome. Majority of
patients belong to moderately & severely retarded group.
• They seem normal from birth to 6 months of age.
CONT…

Phenylketonuria (P.K.U):
• PKU is a genetically inherited metabolic disorder in which the body lacks the enzyme, phenylalanine
hydroxylase (PAH), which is responsible for metabolizing the amino acid called phenylalanine.
• Phenylalanine is involved in the production of the neurotransmitters norepinephrine and dopamine,
which are essential for the proper functioning of the brain and nervous system.
• Patients are severely retarded but some are with borderline/normal intelligence.
• PKU children are hyperactive, with unpredictable behaviours which make them difficult to be
managed.
CONT…

Maple syrup urine disease:
• Maple syrup urine disease (MSUD) is a rare but serious inherited
condition. It means the body cannot process certain amino acids (the
"building blocks" of protein), causing a harmful build-up of substances
in the blood. leucine, isoleucine and valine
• Symptoms appear during first week of life.
• Infant deteriorates rapidly and develops rigidity, seizures, respiratory
irregularity and hypoglycaemia.
• If untraced most of the infant die in the first month of life and the
survivors are severely retarded.
CONT…

• Prenatal factors that result in early alterations in embryonic development account
for approximately 30 percent of intellectual disability cases.
• Damages may occur in response to toxicity associated with maternal ingestion of
alcohol or other drugs.
• Maternal illnesses and infections during pregnancy (e.g. rubella and
cytomegalovirus) can also result in congenital intellectual disability, as can
complications of pregnancy such as uncontrolled diabetes.
2. EARLY ALTERATIONS IN
EMBRYONIC DEVELOPMENT

• Approximately 10 percent of cases of intellectual disability are the
result of factors that occur during pregnancy (e.g. fetal malnutrition,
viral and other infections and prematurity) or during the birth process.
• Examples of the latter include trauma to the head incurred during the
process of birth, premature separation of the placenta and prolapsed of
the cord.
3. PREGNANCY AND PERINATAL
FACTORS

• These conditions account for approximately 5 percent of cases of
intellectual disability.
• They include infections such as meningitis and encephalitis;
poisonings such as from insecticides, medications, lead and physical
trauma such as head injuries, hyperpyrexia.
4. GENERAL MEDICAL CONDITIONS
ACQUIRED IN INFANCY OR CHILDHOOD

 Poverty
Children in poor families may suffer because of malnutrition, disease producing
conditions, inadequate medical care and environmental health hazards.
 Lead poisoning:
Has a high incidence among low income families. 3-20% of children below age
6yrs have lead poisoning which can cause Intellectual disability.
5. ENVIRONMENTAL INFLUENCES AND OTHER
MENTAL DISORDERS

LEVELS OF INTELLECTUAL DISABILITY
IQ Type I Type II Description
50 – 75 Mild Educable  Can develop social and sensorimotor
skills.
 Can be self-supporting.
35 – 49 Moderate Trainable  Can communicate.
 Minimal learning ability.
 Poor social interaction skills, but can
be independent with supervision.
20 – 34 Severe Trainable  Poor communication, social and
sensorimotor skills.
 Needs supervision and can benefit
from habit training.
Below 20 Profound Custodial  Minimal capacity to function.
 Needs constant supervision.

DEVELOPMENTAL CHARACTERISTICS OF INTELLECTUAL
DISABILITY BY DEGREE OF SEVERITY
Level (IQ) Ability to
Perform Self-
Care
Activities
Cognitive/
Educational
Capabilities
Social/
Communication
Capabilities
Psychomotor
Capabilities
Mild
(50-70)
Capable of
independent
living with
assistance
during times
of stress.
Capable of
academic skills to
sixth grade level.
As adult can
achieve vocational
skills for minimum
self-support.
Capable of
developing social
skills. Functions
well in a structured,
sheltered setting.
Psychomotor skills
usually not
affected, although
may have some
slight problems
with coordination.
Moderate
(35-49)
Can perform
some
activities
independently
. Requires
supervision.
Capable of
academic skill to
second grade level.
As adult may be
able to contribute to
own support in
sheltered workshop.
May experience
some limitations
speech
communication.
Difficulty adhering
to social convention
may interfere with
peer relationships.
Motor
development is
fair. Vocational
capabilities may be
limited to
unskilled gross
motor activities

CONT…
Moderate
(35-49)
Can perform
some
activities
independently
. Requires
supervision.
Capable of
academic skill to
second grade level.
As adult may be
able to contribute to
own support in
sheltered workshop.
May experience
some limitations
speech
communication.
Difficulty adhering
to social convention
may interfere with
peer relationships.
Motor
development is
fair. Vocational
capabilities may be
limited to
unskilled gross
motor activities
Severe
(20-34)
May be
trained in
elementary
hygiene skills.
Requires
complete
supervision.
Unable to benefit
from academic or
vocational training.
Profits from
systemic habit
training.
Minimal verbal
skills Wants and
needs often
communicated by
acting-out behaviors.
Poor psychomotor
development only
able to perform
simple task under
close supervision
Profound
(Below 20)
No capacity
for
independent
functioning.
Requires
constant aid
and
supervision.
Unable to benefit
from academic or
vocational training.
May respond to
minimal training in
self-help if
presented in the
close context of a
one to one
relationship
Little if may speech
development. No
capacity for
socialization skills
Lack of ability for
both fine and gross
motor movements.
Requires constant
supervision and
care. May be
associated with
other physical
disorders.

• Nurses should assess and focus on each client’s strengths and
individual abilities.
• Knowledge regarding level of independence in the
performance of self care activities is essential to the
development of an adequate plan for the provision of nursing
care.
CONT…

 Delays in oral language development.
 Deficits in memory skills.
 Difficulty with learning social rules.
 Difficulty with problem solving skills.
 Delays in the development of adaptive behaviour such as self-help or self care
skills.
 Lack of social interests.
OTHER SIGNS

 A head that is too large or too small.
 Deformities of the hands or feet.
 Some have normal appearance but have other signs such as seizures,
lethargy, vomiting, abnormal urine odour & failure to feed.
 Usually, the first problem parents notice is a delay in language
development.
 May be gullible and easily taken advantage of or led into minor
misbehaviour.
SYMPTOMS

 Delayed development of motor skills, & are slow to roll, sit and stand.
 Slower to use words, put them together & speak complete sentences.
 Development is sometimes slow.
 May be slow to learn to dress & feed themselves.
 Unable to keep up with age-appropriate expectations.
 Have behavioural problems, such as explosive outbursts, temper
tantrums, and physically aggressive behaviour.
CONT…

COMMON HEALTH PROBLEMS ASSOCIATED WITH
INTELLECTUAL DISABILITY
Behavioral Problems
 Restlessness
 Poor concentration
 Impulsiveness
 Temper-tantrum
 Irritability
 Crying
 Self injurious behavior (head banging).
Convulsive or fits
Sensory impairment
 Vision difficulty
 Hearing difficulty
Other developmental disabilities
 Speech problems
 Autism

The DSM-5 diagnosis of ID requires the satisfaction of three criteria:
1. Deficits in intellectual functioning “reasoning, problem solving, planning,
abstract thinking, judgment, academic learning, and learning from experience”
confirmed by clinical evaluation and individualized standard IQ testing.
2. Deficits in adaptive functioning that significantly hamper conforming to
developmental and socio cultural standards for the individual's independence
and ability to meet their social responsibility.
3. The onset of these deficits during childhood.
DSM V CRITERIA FOR DISORDERS OF
INTELLECTUAL DEVELOPMENT

1. Cognitive impairment: IQ score approximately 70 or below.
2. Adaptive functioning deficits: Impairments in daily life skills, social
participation and independent living.
3. Early onset: During developmental period, typically before age 18.
4. Significant support needs: Ongoing support required in daily life.
Both DSM & ICD emphasize the importance of assessing cognitive and adaptive
functioning, as well as considering the individual's support needs.
Note:- IQ scores are not the sole determining factor for ID diagnosis. Adaptive
functioning deficits are essential for diagnosis. Both systems consider the individual's
overall functioning and support needs.
ICD 11 CRITERIA FOR DISORDERS OF
INTELLECTUAL DEVELOPMENT

• History
• Psychiatric Interview
• Physical examination
• Neurological examination
• Psychological assessment
DIAGNOSTIC EVALUATION

• The history is most often obtained from the parents or the caretaker,
with particular attention to the mother's pregnancy, labor, and delivery;
the presence of a family history of intellectual disability,
consanguinity of the parents and hereditary disorders.
• As part of the history, the clinician assesses the overall level of
functioning and intellectual capacity of the parents and the emotional
climate of the home.
HISTORY

• Two factors are of paramount importance when interviewing the patient: the
interviewer's attitude and manner of communicating.
• The patient's verbal abilities, including receptive and expressive language, should be
assessed as soon as possible by observing the communication between the caretakers
and the patient and by taking the history.
• The patient's control over motility patterns should be ascertained, and clinical evidence
of distractibility and distortions in perception and memory may be evaluated.
• In general, the psychiatric examination of a retarded person should reveal how the
patient has coped with the stages of development.
PSYCHIATRIC INTERVIEW

• For example, the configuration and the size of the head offer clues to a
variety of conditions, such as microcephaly, hydrocephalus and Down
syndrome.
• The patient's face may have some signs of intellectual disability that
greatly facilitate the diagnosis, such as hypertelorism, a flat nasal
bridge, prominent eyebrows, epicanthal folds, retinal changes, low set
and small or misshapen ears, a protruding tongue, and a disturbance in
dentition.
PHYSICAL EXAMINATION

 Hearing impairment
 Visual disturbances
 Seizure disorder
 Poor coordination
NEUROLOGICAL EXAMINATION

 Intelligence tests to measure the learning abilities & intellectual functioning e.g. The
Stanford-Binet Intelligence Scale (>2 years age), The Wechsler Intelligence Scale (6-
16 years age) & The Kaufman Assessment Battery for Children (3-18 years age).
 For infants, Bayley Scale of Infant Development is used.
 Draw a Person Test
 Geometric puzzles
 The Woodcock-Johnson Scale of Independent Behaviour and the Vineland Adaptive
Behaviour Scale (VABS) are frequently used to evaluate the child's daily living,
muscle control, communication, and social skills.
PSYCHOLOGICALASSESSMENT

TIPS FOR PARENTS
• Ask for help, learn about your child’s disability.
• Connect with other parents of children with disabilities.
• Be patient; learning may come slower for your child.
• Encourage independence and responsibility.
• Educate yourself on the educational services your child deserves.
• Learn the laws that are written to help your child live their best life.
• Look for opportunities in your community for social, recreational and sports
activities.

NURSING MANAGEMENT
DIAGNOSE 1: Risk for injury related to altered physical mobility or aggressive behavior.
SPECIFIC OBJECTIVE: Client will not experience injury.
NURSING INTERVENTIONS RATIONALE
 Create a safe environment for the client.
 Ensure that small items are removed from area
where client will be ambulating and that sharp items
are out of 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.
 Ensure the safety of the client.

CONT…
DIAGNOSE 2: Self care deficit related to altered physical mobility.
SPECIFIC OBJECTIVE: Client will be able to participate in aspects of self-care.
 Identify aspects of self-care that may be within the
client’s capabilities.
 Work on one aspect of the self-care at a time.
 Provide simple, concrete explanations.
 Offer positive feedback for efforts.
 When one aspect of self-care has been mastered to
the best of the client’s ability, move on to another.
 Encourage independence but intervene when client
is unable to perform.
 Positive reinforcement enhances
self-esteem and encourages
repetition of desirable
behaviors.
 Client comfort and safety are
nursing priorities.

CONT…
DIAGNOSE 3: Impaired verbal communication related to altered developmental retardation.
SPECIFIC OBJECTIVE: Client will be able to communicate needs and desires to staff.
 Maintain consistency of staff assignment over time.
 Anticipate and fulfill client’s needs until satisfactory
communication patterns are established.
 Learn 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.
 Consistency of staff
assignments facilitates and the
ability to understand client’s
actions and communications.
 Some children with mental
retardation, particularly at the
several level, can only by
systematic habit training.

DIETARY RECOMMENDATIONS AVOIDED
1. Excessive sugar: Can lead to weight gain, dental problems, and increased risk
of chronic diseases like diabetes and heart disease.
2. Saturated and trans fats: Can increase cholesterol levels, heart disease risk,
and negatively impact cognitive function.
3. High-sodium foods: Can lead to high blood pressure, heart disease, and stroke.
4. Caffeine and nicotine: Can exacerbate anxiety, agitation and behavioral issues,
and lead to addiction.
5. Artificial additives: Can trigger adverse reactions, such as hyperactivity, and
negatively impact overall health.

CONT…
6. Unhealthy snacks: Can lead to weight gain, dental problems and displace more
nutritious food options.
7. Inadequate hydration: Can cause fatigue, headaches, and negatively impact
cognitive function.
8. Food allergens: Can trigger allergic reactions, which can be life-threatening in
severe cases.
9. Inconsistent eating habits: Can lead to energy crashes, mood swings and
negatively impact overall health and well-being.

Intellectual disability (Childhood disorder)

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