KMC COLLAGE OF NURSING

MEERUT

Depth paper
ON
Mental retardation

Submitted to Submitted By

Ms. Zeba Azam Tyagi Ms Sashi Aashiyan

Professor of Psychiatric Nursing MSc Nursing 2nd year

MENTAL RETARDATION
INTRODUCTION:
Mental retardation is incomplete development of mental endowments. This results in failure of
development of sufficient intellectual and cognitive capacity to cope up with the demands of the
environment and to establish an independent social existence and in personality limitation. There is
impairment of maturation, learning and social adjustment.
It is a common developmental disorder, the synonyms used for mental retardation are: Mental
Deficiency/ Mental Defectiveness/ Mental Handicap/ Mental Subnormality/ Mentally Challenged.

DEFINITION:
 Mental retardation is defined by deficits in general intellectual functioning and adaptive
functioning. - (APA, 2000)
 Mental retardation is defined as significantly subaverage general intellectual functioning
resulting in, or associated with, concurrent impairment in adaptive behavior and manifested
during the developmental period, before the age of 18.
-According to DSM-IV-TR
 A condition of arrested or incomplete development of the mind, characterized by impairment of
skills manifest during developmental period that contribute to cognitive, language, motor and
social abilities. - ICD 10
- General intellectual functioning is measured by individual’s performance on intelligent quotient
(IQ) tests.
- Significantly subaverage means 2 standard deviations below the mean (usually an IQ of below
70)
- Adaptive functioning refers to the person’s ability to adapt the requirements of daily living and
expectations of his or her age and cultural group OR person’s ability to meet the responsibilities
of social, personal, occupational and interpersonal areas of life according to his age and
sociocultural and educational background. Adaptive behavior is measured by clinical interview
and standardized assessment scales.

EPIDEMIOLOGY
The incidence of mental retardation is difficult to calculate because mild mental retardation
sometimes goes unrecognized until middle childhood. In some cases, even when intellectual function
is limited, good adaptive skills are not challenged until late childhood or early adolescent and the
diagnosis is not made until that time.
 Mental retardation affects about 2–3% of people. 75–90% of the affected people have mild
retardation.
 Mild mental retardation represents approximately 85% of persons with mental retardation.
 Like wise moderate mental retardation represents 10%, severe 4% and profound 1 to 2% of
persons with mental retardation.
 Non-syndromic or idiopathic MR accounts for 30–50% of cases.
 The highest incidence is in school age children, with the peak age 10 to 14 years.
 MR is about 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 rates because of the complications of associated physical disorders.

DSM-IV-TR DIAGNOSTIC CRITERIA FOR MENTAL RETARDATION

A. Significantly subaverage general 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 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, work,
leisure, health and safety.
C. The onset is before age 18 years.
Code based on degree of severity reflecting level of intellectual impairment:
Mild mental retardation : IQ level 50-55 to approximately 70
Moderate MR : IQ level 35-40 to 50-55
Severe MR : IQ level 20-25 to 35-40
Profound MR : IQ level below 20 or 25
MR, severity unspecified : when there is strong presumption of mental retardation but the
person’s intelligence is untestable by standard tests.

PREDISPOSING FACTORS
The DSM-IV-TR (APA, 2000) states that the etiology of mental retardation may be primarily
biological or primarily psychosocial, or some combination of both. In approximately 30 to 40% of
individuals seen in clinical settings, the etiology cannot be determined. Major predisposing factors
have been identified are:
Hereditary factors
Hereditary factors are implicated as the cause in approximately 5 percent of the cases. They include
inborn errors of metabolism, such as Tay-Sachs disease, phenylketonuria and hyperglycemia. Also
included are chromosomal disorders, such as Down syndrome and Klinefelter syndrome and single
gene abnormalities, such as tuberous sclerosis and neurofibromatosis.

Acquired and developmental factors

Early alterations in embryonic development
Prenatal factors that results in early alterations in embryonic development account for approximately
30% of mental retardation cases. Damages may occur in response to toxicity associated with
maternal ingestion of alcohol or other drugs. Maternal illness and infections during pregnancy (e.g.
rubella, cytomegalovirus, syphilis, toxoplasmosis, herpes simplex) and complications of pregnancy
(e.g. toxemia, uncontrolled diabetes) also result in congenital mental retardation.
Pregnancy and perinatal factors
Approximately 10% of cases of mental retardation 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 birth, placenta previa or
premature separation of the placenta and prolapse umbilical cord.
Recent studies have documented that, among children with very low birth weight (less than 1000g),
20% had significant disabilities, including cerebral palsy, mental retardation, autism and low
intelligence with severe learning problems.
General medical conditions acquired in infancy or childhood
General medical conditions acquired during infancy or childhood account for approximately 5% of
cases of mental retardation. They include infections, such as meningitis and encephalitis; poisonings,
such as from insecticides, medications and lead; and physical trauma, such as head injuries,
asphyxiation and hyperpyrexia.
Iodine deficiency, affecting approximately 2 billion people worldwide, is the leading preventable
cause of mental disability in areas of the developing world.
Environmental influences and other mental disorders
Between 15-20% of cases of mental retardation are attributed to deprivation of nurturance and social,
linguistic and other stimulation and to serve mental disorders, such as autistic disorder. (APA, 2000)
- Prenatal environment compromised by poor medical care and poor maternal nutrition can be
contributing factors in the development of mild mental retardation.
- Family disability, frequent moves and multiple but inadequate caretakers may deprive an infant
of necessary emotional relationships, leading to failure to thrive and potential risk to the
developing brain.

CLASSIFICATION OF MENTAL RETARDATION:

Degree of mental retardation IQ level
Mild MR (85-90%) 50- 70* Educable
Moderate MR (10%) 35-50* Trainable
Severe MR 20-35* Dependent
Profound MR (1-2%) < 20* Life support

Developmental characteristics of mental retardation by degree of severity:

Level Ability to perform Cognitive/ Social/ Psychomotor
(IQ) self care activities educational communication capabilities
activities capabilities
Mild Capable of Capable of academic Capable of Psychomotor skills
(50-70) independent living, skills to sixth grade developing social usually not
with assistance level. As adults can skills. Functions affected, although
during times of achieve vocational wall in a structured, may have some
stress. skills for minimum sheltered setting. slight problems
self support. with coordination.
Moderate Can perform some Capable of academic May experience Motor
(35-49) activities skills to second some limitation in development is
independently. grade level. As adult speech fair. Vocational
Require supervision. may be able to communication. capabilities may be
contribute to own Difficulty adhering limited to unskilled
support in shelter to social convention gross motor
workshop. may interfere with activities.
peer relationships.
Severe May be trained in Unable to benefit Minimal verbal Poor psychomotor
(20-34) elementary hygiene from academic or skills. Wants and development. Only
 skills. Requires vocational training. needs often able to perform
complete Profits from communicated by simple tasks under
supervision. systematic habit acting out close supervision.
training. behaviors.
Profound No capacity for Unable to profit Little, if any, Lack of ability for
(below independent from academic or speech both fine and
20) functioning. vocational training. development. No motor movements.
Requires constant May respond to capacity fort Requires constant
aid and supervision. minimal training in socialization skills. supervision and
self help if presented care. May be
in the close context associated with
of a one to one other physical
relationship. disorders.

CLINICAL MENIFESTATIONS
 Continued infant-like behavior
 Decreased learning ability
 Failure to meet the markers of intellectual development
 Inability to meet educational demands at school
 Lack of curiosity
In infancy
 Poor feeding lead to poor weight gain, evidenced by uncoordinated sucking either breast or bottle
 Delayed visual alertness and curiosity
 Decreased or lack of auditory response
 Decreased spontaneous activity
 Delayed head or trunk control, delayed milestones
 Floppy or spastic muscle tone
 Abnormalities in physical and neurological unusual facial features
 Delayed development in moor skills crawling, sitting and standing
In toddler
 Delayed independent living skills, sitting and ambulation
 Delayed communication failure to develop receptive and expressive language, delayed speech,
slower to use words
 Disinterested or slow to learn, self care
 Cognitive impairment- shorter attention span and distractibility
 Behavioural disturbances, clumsiness
 Impaired ability to communicate to others and control impulses

DIAGNOSIS
The diagnosis is made by the following steps:
1. History : the history is most often obtained from the parents or the care takers, with particular
attention to the :
o Mother’s pregnancy, labor and delivery
o Presence of a family history of mental retardation
o Consanguinity of the parents
o Hereditary disorders
Clinicians assesses the overall level of functioning and intellectual capacity f the parents and the
emotional climate of the home.
2. General physical examination: various parts of the body may have certain characteristics that
have prenatal causes and are commonly found in persons who are mentally retarded. E.g. the
patient’s face have some signs of mental retardation such as a flat nasal bridge, prominent
eyebrows, retinal changes, protruding tongue etc.
3. Detailed neurological examination: for assessing any hearing and visual abnormalities. Also
assessing seizure disorders because it is estimated that about 10% of all mentally retarded
children suffered from seizure disorder.
4. Mental status examination: for the assessment of associated psychiatric disorders and the
clinical assessment of the level of intelligence.
5. Investigations
o Routine investigations
o Urine test e.g. for phenylketonuria
o EEG, especially in the presence of seizures
o Blood levels, for inborn errors of metabolism
o Chromosomal studies
o CT scan or MRI of brain
o Thyroid function test
6. Psychological tests: the commonly used tests for the measurement of intelligence include:
o Seguin form board test
o Stanford Binet test for 2 years or more (mental abilities)
o Wechsler intelligence Scale for children (WISC) for 61/2 to 16 years of age.
o Wechsler Preschool and Primary Scale of Intelligence (WPPSI) for 4 to 61/2 years of age
o Bhatia’ s battery of performance test
o Vineland Social Maturity Scale for social adaptive abilities (self help skills, self control,
interaction with others)

CO MORBIDITY
 Attention deficit hyperactivity disorder and conduct disorder
 Those with severe mental retardation have a particularly high rate of autistic disorder and
pervasive development disorder.
 2 to 3% meet the criteria of schizophrenia
 Aggression and self injurious behavior
 Depressive disorder
 Stereotypical motor movements

DIFFERENTIAL DIAGNOSIS
The diagnosis of mental retardation is usually simple. However, while making this diagnosis, the
following conditions must keep in mind, as these can be mistaken with mental retardation.
 Deaf and dump
 Isolated speech defects
 Psychiatric disorders, like infantile autism, childhood onset schizophrenia
 Epilepsy
 Chronic brain syndrome can result in isolated handicaps—failure to read, write, communicate
etc—that can exist in a person with normal and even superior intelligence.
 Children under the age of 18 years who meet the diagnostic criteria for dementia and who have
an IQ below 70 are given the diagnosis of dementia and mental retardation. Those whose IQ drop
below 70 after the age of 18 years and who have new onsets of cognitive disorders are not given
the diagnosis of mental retardation but only the diagnosis of dementia.

MANAGEMENT
The treatment of individuals with mental retardation is based on the assessment of social,
educational, psychiatric and environmental need. Mental retardation is associated with a variety of
comorbid psychiatric disorders that often require specific treatment, in addition to psychosocial
support. The major aspects of caring for children withMR include
(1) health (growth, developmental, andbehavioral surveillance, and mental and dental health);
(2) developmental and educational interventions;
(3)community integration through social and recreational activities.
Preventive measures are taken. In general
1. Genetic: Prenatal screening for genetic defects and genetic counseling for families at risk for
known inherited disorders can decrease the risk of inherited intellectual disability.
2. Social: Government nutrition programs are available to poor children in the first and most critical
years of life. These programs can reduce disability associated with malnutrition. Early
intervention in situations involving abuse and poverty will also help.
3. Toxic: Environmental programs to reduce exposure to lead, mercury, and other toxins will
reduce toxin-associated disability. However, the benefits may take years to become apparent.
Increased public awareness of the risks of alcohol and drugs during pregnancy can help reduce
the incidence of disability.
4. Infectious: The prevention of congenital rubella syndrome is probably one of the best examples
of a successful program to prevent one form of intellectual disability. Constant vigilance, such as
that can cause toxoplasmosis during pregnancy, helps reduce disability that results from this
infection.

1. Primary prevention: this consist of

 Improvement in socio economic condition of society at large, aiming at elimination of
understimulation, malnutrition, prematurity and perinatal factors.
 Education of lay public, aiming at the removal the misconceptions about individuals with mental
retardation.
 Medical measures for good perinatal medical care to prevent infections, trauma, excessive use of
medications, malnutrition, obstetric complications and diseases of pregnancy.
 Universal immunization of children with BCG, polio, DPT and MMR.
 Facilitating research activities to study the causes of mental retardation and their treatment.
 Genetic counseling in at risk parents e.g. in Down’s syndrome.
2. Secondary prevention:
 Early detection and treatment of preventable disorders e.g. phenylketonuria (low phenylalanine
diet), hypothyroidism (thyroxine) etc.
 Early detection of handicaps in sensory, motor or behavioral areas with early remedial measures
and treatment.
 Early treatment of correctable disorders, e.g. infections (antibiotics), skull configuration
anomalies (surgical correction).
 Early recognition of presence of mental retardation. A delay in diagnosis may cause unfortunate
delay in rehabilitation.
 As far as possible, individuals with mental retardation should be integrated with normal
individuals in society, and any kind of segregation or discrimination should be actively avoided.
Special schools must be their for those with more severe mental retardation.
3. Tertiary prevention:
 Adequate treatment of psychological and behavioral problems.
 Behavior modification, using the principles of positive and negative reinforcement. Behavior
therapy has been used to shape and enhance social behaviors and to control and minimize
aggressive and destructive behavior.
 Rehabilitation in vocational, physical and social areas. Certain rehabilitation programmes are
carried out to engage the child in useful activities. The main goal of providing such programmes
are:
 Permits the child to develop work attitude and acceptable working skills.
 Provides self support by earning themselves by gaining working skills.
 Parental counseling is extremely important to lessen the levels of stress and teaching them to
adapt the situation. Parental counseling should focus on:
- Giving information regarding the condition of mentally retarded child.
- Developing the right attitude towards the handicapped child.
- Mentally retarded children improve with training but slowly.
- Marriage is not a cure for mental retardation.
- Educating the parents regarding their role in the training of the mentally retarded child.
- Mentally retarded children require good food, love and affection, special education and
training and good social support.
 Institutionalization or residential care may be needed for individuals with profound mental
retardation. Indications for institutionalization of mentally retarded children are behavioral
difficulties like destructive behavior, assaultive behavior, psychosis, social factors e.g. no one to
look after, single parenthood, incompetent parents.
 Recreational therapeutic activities: Provide physical training e.g. gymnastics and entertaining
activities like music, dancing, reading, in door games etc. socializes the client by engaging the
child to participate in play and stimulates sensory and motor responses.
 Social interventions:
 Drug therapy:
 No specific drugs are available.
 Neuroleptic drugs to reduce aggressiveness and antisocial behavior e.g. phenothiazines.
 Antidepressants
 Special schools: Education must be provided in the least restrictive, most inclusive settings,
where the children have every opportunity to interact with non- disabled peers and have equal
assess to community.
  One of the major goals of special school for the mentally challenged is to enable the students
to become productive members of the society.
 Emphasizes the child development and adjustment: teacher has to be sensitive, well adjusted
and provides learning opportunities, life experiences, physical training, speech training,
works for total development of the child, meeting hygienic needs of the MR children by “3R”
principle, i.e. Repition, Reinrorcement, Rehearsal.
 Step wise training programmes will be conducted like: prevocational and vocational training.
Teaching Tips for Kids with Mild Intellectual Disabilities
1. Develop His Language Skills
2. Make Math Manageable
3. Increase His Attention Span: Kids with mild intellectual difficulties may have trouble attending
to a task, knowing which parts of the task to focus on, and maintaining attention for long periods
of time. Help child by removing distractions and prompting him to important parts of the tasks.
As child's attention span grows over time, you can increase the task's difficulty.
4. Make Up Memory Mechanisms: If child have difficulty remembering information he has recently
learned teach him short-term memory strategies like repeating the information,
recalling information in clusters, and mnemonic devices
5. Show Him How to Adjust to New Scenarios : Children with mild intellectual disabilities may
have trouble applying skills they learn in one area to a new situation. For example, a student may
learn a new word in English class but have trouble understanding the same word in a science
textbook. Remind child that information they learn in one situation can be applied to different
scenarios. For instance talk with him about how the word "ring" can be used to describe a
specific type of jewelry, a sound that a bell makes, and a circular shape.
6. Open Up Opportunities to Develop Social Skills

How to Teach Mentally Challenged Kids

1. Provide a variety of activities when teaching a lesson. Students with mental challenges learn best
using a combination approach of visual, auditory and kinesthetic experiences. Charts, graphs,
music and lab experiences are examples of activities that would be beneficial.
2. Allow additional time to answer after asking a question. Students with mental retardation and
other learning disabilities often process language slower than typically developing peers. To
employ extended wait time for a student during a lecture, ask the question, continue with the
lesson and return to the student after several minutes of processing time.
3. Break lessons and tasks into smaller parts, and scaffold the lesson so it builds slowly. Students
with cognitive deficits often need step-by-step instruction in everyday activities. For example,
going through the lunch line may require smaller instructions like, "Stand here. Get a fork. Get a
tray. Ask for vegetables. Get milk. Check out at the register."
4. Give directions one-on-one with only one or two steps. Students with mental deficits often need
individual directions with paraphrasing to ensure understanding. Further, they may forget what
they are supposed to do if given too many tasks at a time.
5. Use picture clues to help with task analysis, daily schedule and how to do just about anything.
Students with mental challenges often respond better to a visual picture versus a verbal directive.
6. Treat students with mental challenges as any other student. Promoting independence with peers
supports social and adaptive behaviors of students with learning problems and typically
developing counterparts.
7. Provide a consistent, predictable schedule. Students with cognitive impairments find change
extremely difficult. When a schedule change is unavoidable, give students multiple warnings for
easier transition.
8. Practice consistency in discipline, procedures and expectations. Students with learning
challenges need consistent expectations because adaptive behaviors are deficit, as well. Re-
learning rules and procedures is difficult for students.
9. Give specific feedback when students make errors. Students with mental retardation have
difficulty understanding general correction. For example, when reading aloud, a child may
misread a word. Stop the student at the moment and say the word he missed and instruct him to
point to the word and repeat it correctly.
10. Repeat lessons in a variety of ways. Students with mental challenges are slow to master skills.
Repetition helps move the information from the short-term memory into the long-term memory.
A lesson with multiple steps may take an entire school year or longer to master.

NURSING MANAGEMENT
 Background assessment
 Assess IQ level
 Levels of mental retardation
 Complete physical examination
 Assess strengths and weaknesses
 Assess level of independence in performance of self care activities.

Nursing Goal Nursing interventions Rationale

diagnosis
Risk for injury Client will not - Create a safe environment for - Client safety is
related to experience injury. the client. nursing priority.
physical - Ensure that small items are
mobility or removed from area where
aggressive client will be ambulating and
behavior. that sharp items are out of
reach.
- Store items that client uses
frequently with in easy reach.
- Pad side rails and head board
of the client with history of
seizures.
- Prevent physical aggression
and acting out behaviors by
learning to recognize signs that
client is becoming agitated.
Self care deficit Short term goal: - Identify aspects of self care - Positive
related to Client will be able to that may be with in client’s reinforcement
altered physical participate in aspects capabilities. Work on one enhances self
mobility or lack of self care. aspect of self care at a time. esteem and
of maturity. Long term goal: Provide simple, concrete encourages
Client will have all explanations. Offer positive repetition of desired
self care needs met. feedback for efforts. behavior.
 - When one aspect of self care - Client comfort and
has been mastered to the best safety are nursing
of the client’s ability, move on priorities.
to another. Encourage
independence but intervene
when client is unable to
perform.
Impaired verbal Short term goal: - Maintain consistency of staff - Consistency of staff
communication Client will establish assignment over time. assignment
related to trust with caregivers facilitates trust and
developmental and a means of the ability to
alterations. communication of understand client’s
needs. actions and
Long term goal: communications.
Client needs are - Anticipate and fulfill client’s - Some children with
being met through needs until satisfactory mental retardation,
established means of communication patterns are particularly at the
communication. established. Learn special severe level, can
words client uses that are learn only by
different from the norm. systematic habit
Identify nonverbal gestures or training.
signals that client may use to
convey needs if verbal
communication absent.
Practice these communication
skills repeatedly.
Impaired social Short term goal: - Remain with the client during - The presence of a
interaction Client will attempt initial interactions with others trusted individual
related to to interact with on the unit. provides a feeling
speech others in the - Explain to other clients the of security.
deficiencies or presence of trusted meaning behind some of the - Positive, negative
care giver. client’s nonverbal gestures and and aversive
Long term goal: signals. Use simple language reinforcements can
Client will be able to to explain to the client which contribute to
interact with others behaviors are acceptable and desired changes in
using behaviors that which is not. Establish a behaviors.
are socially procedure for behavior
acceptable and modification with rewards for
appropriate to appropriate behaviors and
developmental level. aversive reinforcement for
inappropriate behaviors.

RESEARCH STUDIES:
Author Research study Findings
M. S. Durkin ,N. Sixty-seven percent of those with serious
Z. Khan et. al mental retardation had cooccurring motor,
Prenatal and Postnatal Risk seizure, vision, and/or hearing disabilities
Factors for Mental Retardation compared with 13 percent of those with
among Children in Bangladesh mild mental retardation and 5 percent of
children without cognitive disabilities.
 Among children with serious mental
retardation, a specific cause of the
disability was identified by the physical
examination and medical history; these
included thyroid disorders (two to iodine
deficiency disorder and postnatal brain
infections.

Social quotient increases from profound to

Indrabhushan Social development of children mild level of retardation. it was found that
Kumar, Amool R. with mental retardation with increasing severity of retardation,
Singh social development also decreases and age
does not have any effect on social
development.

REFERENCES
 Townsend MC. Psychiatric mental health nursing. 4 th ed. USA: Philidelphia; 2002.
 Stuart WG. Principles & practice of psychiatric nursing. 8 th ed. St. Louis: Mosby; 2005.
 Kaplan &Sadock's . Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 10th ed.
New Delhi: Wolters Kluwer; 2007.
 Sreevani R. A Guide to Mental Health& Psychiatric Nursing. 3 rd ed. Kundali: Jaypee; 2010.
 Shapiro BK, Batshaw ML. Intellectual disability. Nelson Textbook of Pediatrics. 19th ed.
Philadelphia: Saunders Elsevier; 2011.