Supervisor

Prof. Sami Lama, Head

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
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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





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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
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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.


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Classifications of Mental
Retardation
Mild (IQ of 5070)
Moderate (IQ of 3549)
Severe (IQ of 2034)
Profound (IQ below 20)

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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.

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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.

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Mild mental retardation - 85 % of persons with MR
Moderate mental retardation (IQ range, 35- 50) - 10 %
Severe mental retardation (IQ range, 20-35) - 4 %

Profound mental retardation (IQ range below 20):- 1-2 %

Prevalence of mental retardation in Nepal is 5.9% (WHO,
country health profile, Nepal).

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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.


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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


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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

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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.

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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.
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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.

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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


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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.

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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).

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Sleep Disorder:
Serious sleep problems such as
obstructed sleep apnoea,
excessive daytime sleepiness and
parasomnias

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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.

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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.

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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.


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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.
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Predisposing Factors for Mental Retardation
Physiological
Inborn error of
metabolism
Chromosomal
Perinatal
Causes
Childhood
illness,
poisoning and
trauma,
nutrition
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Predisposing Factors for Mental Retardation contd
Psychosocial
Understimulation
Consequences of
severe mental
disorder
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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

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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 %.
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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).
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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.
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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


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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
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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
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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
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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
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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.

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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.

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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

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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.

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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
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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.

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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.


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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.

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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
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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.

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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.
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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.

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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

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Compensatory Education:
Compensatory education is intended to provide the
optimal conditions for the mental development of
the child with mental retardation.

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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.


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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.


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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.

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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
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Residential Care
Home care is emphasized

If burden of care is high residential group
home.

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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.
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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.

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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

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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.

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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.

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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.

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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

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Nursing Assessment:
Same as medical Assessment as described earlier.

Common Nursing Diagnoses
Risk for injury
Self-care deficit
Impaired verbal communication
Impaired social interaction


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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.

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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.
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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.
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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.

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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.

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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
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Child with MR should be helped in education,
training and occupation.

Family requires support, respite and guidance
while caring their loved one with MR.
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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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