Mental Retardation and other child psychiatric disorders

CHILDHOOD & ADOLESCENT DISORDERS INCLUDING

MENTAL DEFICIENCYPresented By:

Mr. Sathish. Rajamani M. Sc (N)Department of Psychiatric Nursing

MR Means????

• Mental retardation (MR) diagnosed before age 18, usually in infancy or prior to birth, that includes below-average general intellectual function, and a lack of the skills necessary for daily living.

IQ Formula

IQ = mental age ÷ Physical age × 100

Average IQ level is 100IQ Level below 70 is Mentally Retarded

• General Intellectual Functioning is determined by administering a standardized intelligence test like  Wechsler Adult Intelligence Scale (WAIS)

Adaptive Behavior• Degree with which the individual meets the

standards of personal independence and social responsibilities expected of his age and cultural group.

EPIDEMIOLOGY• 3 % of general populations are MR.• In india 5 : 1000 ratio of MR.• Boys more than Girls• Mortality High in severe and profound

MR due to associated physical illness.

Mild Mental Retardation

• IQ: 50-69

• Largest group of MR patients (about 85%)

• Used to be referred to as “educable”

• As a group, they often develop social, communication, and

motor skills during the preschool years without concern.

• In late teens, can acquire academic skills commensurate with a

6th grader.

Mild Mental Retardation (Cont...)

• Achieve social and vocational skills adequate for minimum self-support, but may need supervision, particularly when stressed.

• Can usually learn to live independently or in supervised settings.

Moderate Mental Retardation• IQ = 35 to 49• About 10% of the MR population• Used to be called “trainable”• Most acquire communication skills during

early childhood.• Can benefit from vocational training and with

moderate supervision, attend to personal care.• Unlikely to progress beyond 2nd grade in

academic subjects.

Moderate Mental Retardation• May learn to travel independently in familiar

places.• Difficulties in social skills and recognizing

social conventions can interfere with peer relationships in adolescence.

• As adults, most can perform unskilled or semiskilled work under supervision.

• Can live in the community, usually with supervision.

Severe MR• IQ 20-34• 3-4% of the MR population• During early childhood, acquire little or no

communicative speech• During school-age period, may learn to talk

and be taught elementary self-care skills.• Unlikely to progress beyond pre-academic

skills (e.g., letter recognition, simple counting) but can master some “survival” sight words.

Severe MR• Most adapt well to life in the

community in group homes or with their family members.

Profound MR• IQ below 20• About 1-2% of the MR population• Most of these individuals have an

identifiable neurological condition that accounts for their MR

• Considerable impairments in early childhood in sensorimotor functioning.

• Optimal development may occur in highly-structured environments.

Profound MR• Motor development, self-care, and

communication skills may improve if appropriate training is provided.

What are the causes

of MR?

CausesTime of onset

A. Prenatal or Biological (before birth)B. Perinatal (during birth)C. Postnatal and Environmental (after birth)

A. Prenatal or Biological (before birth)Prenatal causes are those that originate during conception or pregnancy until before birth are chromosomal disorders such as

Trisomy 21 or Down Syndrome, Klinefelter syndrome, Fragile X syndrome, Prader-Willi syndrome, Phenylketonuria, and William Syndrome.

B. Perinatal (during birth) Mental retardation may occur by:

- Intrauterine Disorders such asmaternal anemia,premature delivery,abnormal presentation,umbilical cord accidents and multiple gestations in the case of twins, triplets, quadruplets and other types of multiple births.Birth trauma may result from anoxia or cutting off of oxygen supply to the brain.

B. Perinatal (during birth) -Neonatal Disorders such as

intracranial hemorrhage, neonatal seizures, respiratory disorders, meningitis, encephalitis, head trauma at birth.

. Postnatal and Environmental (after birth)

mental retardation may occur due to:- head injuries cerebral concussion,

contusion or laceration- infections encephalitis, meningitis,

malaria, German measles, rubella;- demyelinating disorders post

infectious disorders, post immunization disorders

. C. Postnatal and Environmental (after birth)

- Degenerative disorders Rett syndrome, Huntington disease, Parkinson’s disease;

- Seizure disorders – epilepsy, toxic-metabolic disorders such as Reye’s syndrome, lead or mercury poisoning

- Malnutrition – especially lack of proteins and calories;

. C. Postnatal and Environmental (after birth)

- Environmental deprivation such as psychosocial disadvantage, child abuse and neglect, chronic social/sensory deprivation

Signs & SymptomsFailure to achieve developmental milestoneDeficiencies in cognitive functions.Decreased ability to learnDifficulties in expression of emotionsPsychomotor skill deficitsDifficulties in performing self care activitiesNeurologic impairmentsSeizuresIrritability when frustrated or upsetLack of curiosity

DIAGNOSIS1. History taking2. PE, MSE, NEUROLOGICAL EXAMINATIONS3. Assessment of Milestone development4. Investigations includes5. Urine & blood investigations6. Biochemical studies7. Hearing & Speech evaluation8. Amniocentesis9. Chorionic Villi Sampling10. EEG11. CT Scan, MRI12. Thyroid Function Test13. Psychological Tests {Stanford Binnet Intelligence Scale,

Wechsler Intelligence Scale for Children.

TREATMENT• Behavior Management• Environmental Supervision• Monitoring the child developmental needs

and problems• Speech and Language Therapy• Family Therapy• Vocational training

PREVENTION

PRIMARY PREVENTION

PRIMARY PREVENTION• Preconception

1.Genetic counselling,2.Immunization for maternal rubella,

3.Adequate maternal nutrition, 4.Family planning (size. spacing and age of

parents)

PRIMARY PREVENTION

PRIMARY PREVENTION• Gestation• Prenatal care – fetal monitoring and

avoidance of teratogenic substances , exposure to radiation and avoidance of alcohols.

• Analysis of fetus by Amniocentesis, Fetoscopy, biopsy and ultra sound,

PRIMARY PREVENTION• Delivery• Delivery at hospital by doctors• APGAR Scoring• Close monitoring of mother and child• Injection of gamma globulin (Rh –ve

mother)

PRIMARY PREVENTION• Childhood• Proper nutrition (1st 6 months)• Dietary restrictions for specific metabolic

disorders.• Hazards prevention in child environment.

(lead poisoning, head injury etc)

Secondary Prevention• Early detection and prevention of

preventable diseases like PKU, Hypothyroidism.

• Early detection of MR.• Psychiatric treatment for Emotional &

Behavioural problems.

Tertiary Prevention• Training in Vocational, Physical and Social

areas.• Rehabilitation is aimed at reducing the

disability and to provide optimal functioning in a child with MR.

BREAK

F8 – DISORDERS OF PSYCHOLOGICAL DEVELOPMENT

• Specific development of speech and language disorder.

• MR is an generalized impairment in all areas of functioning.

• SDD are characterized by an inadequate development in any one specific area of functioning.

SDD Includes• Reading - Dyslexia • Symptoms

includes1. Late talking2. Learning new words

slowly3. Delay in learning to

read.

DYSARTHRIA & DYSPHASIA

• Dysarthria is a disorder of speech whilst dysphasia is a disorder of language.

DYSCALCULIA

• Severe difficulty in making arithmetical calculations, as a result of brain disorder.

DYSLALIA• A speech defect

caused by malformation of or imperfect distribution of nerves to the organs of articulation (as the tongue)

PERVASIVE DEVELOPMENTAL DISORDER

•  PDD’s refers to a group of conditions that involve delays in the development of many basic skills. Most notable among them are the ability to socialize with others, to communicate, and to use imagination.

HYPERKINETIC DISORDERS

{ADHD}

HYPERKINETIC DISORDERS

{ADHD}

CHARACTERISTICS

• Neurobiological disorder.• Inappropriate attention, Impulsiveness and

hyperactivity.• May progress to conduct disorders.

Aetiology of ADHD• Genetic

– monozygotic twins greater– Twice risk for siblings of hyperactive children

• Biochemical– Deficit of D2 & Norepinephrine.

• Pre, Peri and Postnatal factors– Prenatal toxic exposure– Prematurity, fetal distress, prolonged labor,

asphyxia and low APGAR score.

Aetiology of ADHD• Postnatal factors includes CNS

abnormalities• Environmental Influences

– Food additives, coloring preservatives and use of sugar.

• Psycho – social factors– Prolonged emotional deprivation– Stressful psychic events– Disruption of family equilibrium

RISK FACTORS OF ADHD• Drug exposure in utero• Birth complications• Low Birth Weight• Lead Poisoning

Signs & Symptoms

TYPES

TREATMENT• Pharmacotherapy

– CNS Stimulants: Dextroamphetamine, Methylphenidate, Pemoline.

– TCA, Antipsychotics, SSRI and Clonidine.• Psychological Therapies

– Behavior modification techniques– Cognitive Behavior Therapy– Social Skills Training– Family Education.

CONDUCT DISORDERS• Persistent and significant pattern of conduct

in which the basic rights of others are often violated or rules of society are not followed.

• Characteristic Features of Conduct Disorders– Frequent Lying– Stealing and robbery– Running away from home and school– Physical violence like rape, fire setting, assault,

and use of weapons.– Cruelty towards other people and animals.

ETIOLOGY• Genetic Factors: Higher risk among those

family members affected. Alcoholism and personality disorders in father will increase the chance of illness.

• Biochemical Factors: Elevated plasma levels of testosterone and agressive behavior.

• Organic factors: Brain damage and Epilepsy will increase the risk.

ETIOLOGY• Psycho Social Factors:

– Parental rejection– Harsh discipline– shifting of parental figures– Large family size– Absent father– Parents with ASPD– Divorce in parents– Inadequate communication pattern in the family.

TREATMENTPlacement in a corrective

institutions.Behavioural educationPsychotherapeutic measurementsDrug therapy includes

Anticonvulsant drugsStimulant medicationsLithium and CarbamazapineAntipsychoctics

JUVENILE DELINQUENCY

Juvenile delinquent is a person who is below 16 yrs of age (18

yrs, in case of girls) who indulges in antisocial activities.

SOCIAL CAUSES1.Defects in the family2.Defects in the school

3.Child living in a crime dominated areas

4.War and post war conditions

PSOYCHOLOGICAL CAUSES

1.Personality2.Emotional insecurity

3.Mental illness

ECONOMIC CAUSES1.Poverty - Stealing

2.Prostitution

Reformatory measures1.Probation

2.Reformatory schools, Remand homes

3.Psychological therapies (Play therapy, finger painting &

psychodrama)

TIC DISORDER• Abnormal involuntary movementswhich

occurs suddenly, repetitively, rapidly and is purposeless in nature.

2 Types

• Motor Tics• Characterized by

repititive motor movements

• Verbal Tics• Characterized by

repititive vocalizations.

Gilles de la Tourette’s syndrome

• Special type of chronic tic disorder.• Characterized by

– Multiple motor tics & vocal tics– Duration one year– Onset is usually before 11 yrs of age

MOTOR TICS• Simple Motor

Tics1.Blinking eyes2.Grimacing3.Shrugging of

shoulders4.Tongue

protrusion

• Complex Motor Tics

• Facial gestures • Stamping,• Jumping• Hitting self• Squating• Twirling• Echokinesis• Copropraxia

VERBAL TICS• Simple Vocal Tics

• Coughing• Barking• Throat Clearing• Sniffing• Clicking

• Complex Vocal Tics

• Echolalia• Palilalia• Coprolalia• Mental

Coprolalia

TREATMENT• Haloperidol is a drug of choice.• In severe cases Pimozide or

Clonidine can be used as an adjunct.