INTELLECTUAL DISABILITY

Intellectual disability (ID), formerly known as

mental retardation, is characterized by below-
average intelligence or mental ability and a lack of
skills necessary for day-to-day living. People with
intellectual disabilities can and do learn new skills,
but they learn them more slowly. There are
varying degrees of intellectual disability, from mild
to profound.

What is intellectual disability?

Someone with intellectual disability has
limitations in two areas. These areas are:
 Intellectual functioning: Also known as IQ,
this refers to a person’s ability to learn,
reason, make decisions, and solve problems.
 Adaptive behaviour: These are skills
necessary for day-to-day life, such as being
 able to communicate effectively, interact with
others, and take care of oneself.
DSM-5 defines intellectual disabilities as
neurodevelopmental disorders that begin in
childhood and are characterized by intellectual
difficulties as well as difficulties in conceptual,
social, and practical areas of living. 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 sociocultural
standards for the individual's
independence and ability to meet their
social responsibility
3. The onset of these deficits during
childhood.
Classification of Intellectual Disability
Classification is based on Intelligence Quotient
(IQ) which is equal to Mental Age, i.e. MA, divided
by Chronological Age, i.e. CA, multiplied by 100.
Mild Mental Retardation (50–69):-
Approximately 85% of mentally retarded person
belong to the category of mild level of retardation.
The intellectual ability of a person is equal to that
of 8 to 11 years old average child. The main
features of the mildly retarded children are as
follows:
1. Shows signs of delayed development and
learns to wall, talk, toilet and feed one
year later that the normal child.
2. Slow learner and repeats his grades.
3. Has poor control even on his impulses.
4. Lacks in judgment and fails to expect the
consequence of his actions.
5. Often has speech disturbance.
6. Requires little supervision.
7. Is educable.
Educational Programme for the Mild
Mentally Retarded -
a. The entry in schools should be delayed by
2 to 3 years.
b. In the beginning the retarders should be
made to understand simple arithmetic
concepts, understanding of home and
community and the development of good
work habits.
c. The instructions for formal reading and
writing should begin at the age of 9 to 10.
d. The curriculum for this category of
children should include topics, content and
learning experiences which are relevant for
the development of basic academic skills
and the basic skills of coping with their
environment.
e. All curricular and co-curricular activities
should be based on experience and
concrete situations.
 f. The achievement level in the basic skills
should not be compared with the normal
children.

Moderate Mental Retardation (35–49) :-

Approximately 10% of mentally retarded belong to
the category of moderate level of retardation. The
intellectual ability of this category is equal to that
of six year normal average child. The following
aspects should be considered while planning an
educational programme for these categories of
retardation. The main characteristics are:
i. Shows signs of retardation in almost all areas of
development.
ii. Rate of learning is very slow.
iii. Not expected to acquire basic skills of reading
and writing.
iv. Unable to do any work which requires
consistent attention.
v. Is only trainable and not educable.
vi. Has very deficient capacities and abilities
vii. Is quite unable to do abstract thinking.
Educational Programme for the Moderate
Mentally Retarded-
The children of this category cannot be
educated but they can be trained to obtain certain
basic skills useful for their future lives. The
following considerations should be kept in mind
when framing training programme for this
category of children.
a. The children should be helped to acquire self-
help skills like independent eating, dressing,
toileting, washing and combing hair, brushing
teeth and bathing.
b. The children should be trained in social skills
like greeting people, playing with companions,
following the rules of the road and health rules.
c. The children should be trained in house-hold
skills like dusting and sweeping, washing of
utensils and clothes, using house-hold appliances -
Radio, T.V.
d. The curriculum of training should include
activities for teaching unskilled jobs.
e. The use of material for training should be based
on the use of concrete real objects.
f. The training programme must be based on the
principle of reinforcement.
g. The training should be given on the
development of motor skills and sensory
discrimination.

Severe Mental Retardation (20–34):-

Approximately 3.5% of the mentally retarded fall
in the category of severe mental retardation. They
can reach intellectual level comparable to that of
a four-year average child. The main features of the
severely mentally retarded child are:
i. Grossly retarded in development.
ii. Shows severe motor and speech deficiency.
iii. Has very little interest in his surroundings.
iv. Unable to master the basic skills like feeding
and dressing.
v. Has neither bladder nor bowel control.
vi. Dependent upon others throughout his life.
vii. Neither trainable not educable.
viii. Has the real need for institutionalization.
Educational Programme for Severe Mentally
Retarded-
The children of this category of mentally
retarded children can neither be educated, nor
trained. The following points should keep in view
while dealing with them:
a. The importance in the programme should be on
self-help skills like- feeding, toilet training,washing
and cleaning of their body parts and dressing.
b. The children should be taught to look after
themselves from health and weather hazards,
harmful insects and animals.
c. The implication of the principles of operant
conditioning should be used in teaching them
basic skills like self help skills, household skills,
unskilled occupational skills
Profound Mental Retardation (Below 20):-
The individuals of this group are 1.5% of the total
mentally retarded population. Thus, this group of
mentally retarded has the most severe symptoms
of mental retardation. The children of this
category can never reach intellectual level more
than that of a two year average child. They are
severely deficient both in intellectual capacities
and adaptive behaviour. The main features of the
child belonging to profound category of mental
retardation are as follows:
i. Completely dependent on others and needs care
and supervision as that of an infant.
ii. Has retarded growth, physical deformities,
pathology of central nervous system,mutism,
severe speech disturbances and motor
incoordination.
iii. Unable to meet his physical needs.
iv. Span of life is very short.
v. Needs to be institutionalized.
Provisions of Special Education and Training-
It is an admitted fact that mentally retarded
children cannot be educated along with the
normal children. This is due to the deficits in the
intellectual functioning and the adaptive
behaviour of the mentally retarded children in
comparison to the normal children.

ETIOLOGY –
Factors causing mental retardation
1. Biological factors
a) Genetic: Chromosomal abnormalities such as
the Down’s Syndrome might occur in 1 out of
every 700 births. It accounts for 10% of children
with moderate to severe mental retardation.
Down’s syndrome refers to the three types of
chromosomal aberrations such as,
i) Trisomy-21 where karyotype of mother is
normal,
ii) Mosaicism, with both normal and trisomic cells
and,
iii) translocation between chromosome 21 and 15.
Second common cause is the Fragile-X Syndrome,
characterized by a fragile site at the tip of the long
arm of X-chromosome, which appears as a
constriction. Other chromosomal anomalies such
as Turner’s Syndrome and Klinefelter’s Syndrome
might also contribute to mental retardation.
b) Prenatal causes:
● Infections in mother in the first 3 months of
pregnancy might damage the developing brain of
the foetus such as rubella, herpes, syphilis and
tuberculosis.
● Maternal diseases such as diabetes mellitus and
high blood pressure, chronic problems in the
kidneys and malnutrition in the mother.
Hypothyroidism in mother might lead to birth of
child with cretinism and hyperthyroidism can
cause defects in the central nervous system of the
growing foetus.
c) Perinatal causes:
● Premature birth due to various causes
● Low birth weight
● Lack of respiration
● Hypoxia or lack of respiration
● Excessive coiling of the umbilical cord around
the neck of the foetus
● Severe jaundice in the new born
● Trauma to the head due to disproportion
between foetal head and birth canal, prolonged
labour or delivery by improper use of instruments.
d) Postnatal causes:
● Malnutrition in the child- Brain is vulnerable to
malnutrition during 12—18weeks of
foetal life when multiplication of nerve cells is
very active and from birth to the end of 2nd year
of life. Inadequate intake of proteins and
carbohydrates during this period predisposes to
mental retardation.
● Infections in the child such as meningitis or
encephalitis (brain fever) can lead on to mental
retardation.
● Repeated fits in the child can damage the brain
and lead on to mental retardation.
● Any injury to the brain from accidents or falls
can lead on to mental retardation.
2. Environmental factors
a) Exposure to Certain Types of Toxins or Diseases:
Exposure to heavy metals like mercury and lead
may be also responsible for MR. On the other
hand, some infectious diseases such as meningitis,
whooping cough, measles etc. if not treated
properly may result in MR.
b) Iodine Deficiency: Iodine deficiency is affecting
approximately two billion people in the world.
This deficiency is more common in developing
countries. Iodine deficiency in mother during
pregnancy restricts the growth of brain of the
foetus which leads to hypothyroidism and as a
result of this deficiency, affected foetus will be
mentally retarded because of the restricted brain
growth.
c) Malnutrition: Another very important cause of
MR is malnutrition. This malnutrition affects the
mental ability in the people of the areas affected
by famine. As a result of these famines people
face the problem of nutritional deficiency which
ultimately results in mental retardation.
d) Deprivation of sociocultural stimulation might
also cause MR.
3. Psychiatric factors
a) Childhood developmental disorders under the
spectrum of Pervasive developmental disorders
including autism, Rett’s Syndrome, Asperger’s
Syndrome and other childhood disintegrative
disorders might lead to MR.
b) Emotional disturbances at an early age may
significantly interfere with normal development
and result in behavioural and intellectual
disabilities. The child’s relationship with the
parents, with siblings, parent’s attitude towards
each other and the child unusual and
psychologically traumatic episodes in the child’s
life, perhaps, the disturbances due to prolonged
periods of emotional disturbance or some
increased sensitivity on the part of the child might
result in MR.
c) Onset of psychiatric illnesses in the early
childhood such as schizophrenia, bipolar affective
disorder and several other psychotic disorders
might cause several mental deficiencies in the
growing period leading to mental retardation.

Diagnosis:-
The diagnosis is made by the following steps:
1. History.
2. General physical examination.
3. Detailed neurological examination.
4. Mental status examination, for the assessment
of associated psychiatric disorders and the clinical
assessment of the level of intelligence.
[Link]-
i. Routine investigations.
ii. Urine test, e.g. for phenylketonuria, maple
syrup urine disease.
iii. EEG, especially in presence of seizures.
iv. Blood levels, for inborn errors of metabolism.
v. Chromosomal studies, e.g. in Down's syndrome,
prenatal (by amniocentesis or chorionic villus
biopsy) and postnatal.
vi. CT scan or MRI scan of brain, e.g. in tuberous
sclerosis, focal seizures, unexplained neurological
syndromes, anomalies of skull configuration,
severe or profound mental retardation without
any apparent cause, toxoplasmosis.
vii. Thyroid function tests, particularly when
cretinism is suspected.
viii. Liver function tests, e.g. in
mucopolysaccharidosis
6. Psychological tests
The commonly used tests for measurement of
intelligence include:
i. Seguin form board test.
ii. Stanford-Binet, Binet-Simon or Binet-Kamath
tests.
iii. Wechsler Intelligence Scale for Children (WISC)
for 6% to 16 years of age.
iv. Wechsler's Preschool and Primary Scale of
Intelligence (WPPSI) for 4 to 6% years of age.
v. Bhatia's battery of performance tests.
vi. Raven's progressive matrices (coloured,
standard and advanced).

The tests used for the assessment of adaptive

behaviour include:
i. Vineland Social Maturity Scale (VSMS).
ii. Denver Development Screening Test (DDST).
iii. Gessell's Development Scale.

Differential Diagnosis: -
The diagnosis of mental retardation is usually
simple. However, while making this diagnosis, the
following conditions must be kept in mind, as they
can be and are many times mistaken for mental
retardation, with disastrous results.
1. Deaf and dumb (This possibility must always be
ruled out either by clinical examination and/or by
audiometry).
2. Deprived children, with inadequate social
stimulation (Although this can also cause mental
retardation, many children become 'normal'
intellectually on providing adequate stimulation).
3. Isolated speech defects.
4. Psychiatric disorders (such as infantile autism,
childhood onset schizophrenia).
5. Systemic disorders (without mental retardation
but with physical debilitation).
6. Epilepsy.

Management: -
The management of mental retardation can be
dis-cussed under prevention at primary,
secondary and tertiary levels
Primary Prevention—
1. Improvement in socioeconomic condition of
society at large, aiming at elimination of under-
stimulation, malnutrition, prematurity and
perinatal factors.
2. Education of lay public, aiming at removal of
the misconceptions about individuals with mental
retardation.
3. Medical measures for good perinatal medical
care to prevent infections, trauma, excessive use
of medications, malnutrition, obstetric
complications, and diseases of pregnancy
4. Facilitating research activities to study the
causes of mental retardation and their treatment
5. Genetic counselling in at-risk parents, e.g. in
phenylketonuria, Down's syndrome.
Secondary Prevention—
1. Early detection and treatment of preventable
dis orders, e.g. phenylketonuria (low
phenylalanine diet), maple syrup urine disease
(low branched amino-acid diet) and others as
discussed earlier, hypothyroidism (thyroxine).
2. Early detection of handicaps in sensory, motor
or behavioural areas with early remedial
measures and treatment.
3. Early treatment of correctable disorders, e
infections (antibiotics), skull configuration
anomalies (surgical correction).
4. Early recognition of presence of mental
retardation. A delay in diagnosis may cause
unfortunate delay in rehabilitation.
5. As far as possible, individuals with intellectual
disability should be integrated with normal
individuals in society, and any kind of segregation
or discrimination should be actively avoided. They
should be provided with facilities to enable them
to reach their own full potential. However, there is
a role of special schools for those with more
severe mental retardation.
Tertiary Prevention—
1. Adequate treatment of psychological and
behavioural problems.
2. Behaviour modification, using the principles of
positive and negative reinforcement.
3. Rehabilitation in vocational, physical, and social
areas, commensurate with the level of handicap.
4. Parental counselling is extremely important to
lessen the levels of stress, teaching them to adapt
to the situation.
5. Institutionalization or residential care may be
needed for individuals with profound mental
retardation.
6. Legislation: In 1995, the 'Persons with Dis-
ability Act' came in to being in India. This act
envisages mandatory support for prevention, early
detection, education, employment, and other
facilities for the welfare of persons with
disabilities in general, and ID in particular.
In 1999, the 'National Trust Act' came in to
force. This Act proposes to involve the parents of
mentally challenged persons and voluntary
organizations in setting up and running a variety of
services and facilities with governmental funding