MENTAL RETARDATION: IDENTIFICATION, ASSESSMENT AND MANAGEMENT

MENTAL RETARDATION: IDENTIFICATION, ASSESSMENT AND MANAGEMENT

P. T. SASI M PhiL, PhD

Consultant Psychologist

Elite Mission Hospital, Trichur.

There are many definitions of mental retardation. Mental retardation, mental deficiency, mental subnormality and mental handicap are the terms used to denote the same condition. The terms used in the past such as amentia, idocy, feeble mindedness, moron, imbecility and oligophrenia are now obsolete. The most comprehensive definition of mental retardation was developed by the American Association on Mental Retardation (AAMR). According to AAMR mental retardation.

"Significantly subaverage general intellectual functioning resulting in or associated with concurrent impairments in adaptive behaviour and manifested during the developmental period" (Grossman, 1983).

1.0 Classification

The terms currently used to describe the various degrees of mental retardation are mild, moderate, severe and profound. People are considered to be mild mental retarded if the score between 50 and 70 on an intelligence test. They are also called educable mentally retarded having the potentials for educability in functional reading, arithmetic, capacity for social adjustment to a point where he/she can get along independently in the community and occupational adequacy which helps him to support himself partially.

Moderate mental retardation applies to IQ scores within the range of 35-50. They are trainable with the potentials of learning self care activities such as eating, dressing, undressing, toileting etc. and to adjust in the home or neighbourhood though not in the total community for development.

Profound mental retardation refers to IQ Scores that fall below 20. This group is also called custodial mentally retarded. Though multiple, handicaps may be associated with many profoundly retarded people. with proper training they can learn self care skills.

2.0 Prevalence

The prevalence of mental retardation in india is estimated at 2% of population. The overwhelming majority (80%) of mentally retarded fall into mild category. Moderate is 12% and severe and profound is 7% and less than 1% respectively

3.0 Aetiology

Various prenatal and postnatal causes account for the genesis of mental retardation.

Prenatal causes include chromosomal abnormalities, genetic disorders, Maternal diseases, diabetes mellitus and endocrine disorders. Maternal infection during the first trimester can damage the developing brain (eg. Rubella); untreated seizure disorders in the mother and use of drugs with known teratogenic potential during first trimester can result in congenital abnormalities in the foetus including mental retardation.

Perinatal causes include premature birth, low birth weight, obstetric trauma, malposition of the foetus, placenta praevia and abruptio placenta, toxaemias of pregnancy, severe neonatal jaundice etc.

Postnatal causes include malnutrition in the child, neonatal infections (eg. Menigitis/ encephalitis), trauma to the brain etc.

4.0 Identification

Early identification of mental retardation can be made by seeing how much a child is delayed on the milestones of development. Some of the common milestones of development and the approximate age of their attainment relevant to Indian context are given in Appendix A.

5.0 Assessment

The intellectual functioning and adaptive behaviour in a mentally retarded are assessed using a combination of test and schedules. The important aread of assessment in mentally retarded persons are :

a) Measurement of the overall level of general intellectual functioning.

b) Assessment of adaptive behaviour

c) Analysis of individual abilities and deficits.

Tests used in India for assessing general intelligence in mental retardation can be categorized into three group

5.1 Developmrntal schedules :

These schedules are based on observations of the development of sensory motor activity in infants and preschool children. The measure of intelligence on developmental schedules is expressed in terms of developmental quotients(DQ's). Some of the widely accepted scales in this category are :

5.1a Bayley infant scales

5.1b Gassell's developmental schedules

5.1c NIMH development assessment schedules.

5.2 Verbal tests

5.2a Binet Kamat test

5.2b Binet Kulshresta test

5.2c Malin's intelligence test for Indian children.

The verbal tests involve the predominant use of language and have oral items and intelligence is marked in terms of intelligence quotient (IQ's)

5.3 Nonverbal and performances tests :

5.3a Developmental screening test

5.3b Raven's progressive matrices

5.3c Seguin form board test

5.3d Gassel's drawing test

5.3e Malin's intelligence scale for Indian Children-performance scale

5.3f Alexander pass-along test

5.3g Draw-A-Man test

5.3h Koh's block design test

Performance tests are culture fair and require the subjects to express their answers in the form of drawing, gestures, activities such as arranging blocks and puzzles, matching designs and placing pictures meaningfully. Scores on this tests are expressed as performance Quotients (PQ's)

5.4 Adaptive behaviour :

It is the functional ability of the individual to exercise personal independence and social responsibility. The most commonly used scales are.

5.4a Vineland social maturity scale.

5.4b American association of mental retardation adaptive behaviour scale.

5.5 Individual abikities and deficits :

For the proper planning of training programmes detailed assessment of specific abilities are essential. The areas in which detailed assessment is required are attention span, gross and fine motor skills, language and communication skills, visuoperceptual, spatial and visuomotor abilities. The tests available for the purposes are :

5.5a Digit span test

5.5b Cancellation test

5.5c Knox cube imitation test

5.5d Madras development programming system (MDPS ) behavioural scale.

5.5e Bender gestalt test (BGT)

5.5f Bender visual retention test (BVRT)

5.5g Draw-A-Man test

5.5h Memory for design test

Common fine and gross motor skills and approximate age of acquisition are given in appendix B and C respectively.

6.0 Associated problems in Mental Retardation

A part from the deficits in intelligence and adaptive behaviour, mental retardation may be linked with medical problems or associated handicaps. Some of the most common neuropsychiatric problems are :

6.1 Seizure disorder

6.2 Hyperkinesis

6.3 Autistic behaviour

6.4 Schizophrenia

6.5 Mania

6.6 Depression

6.7 Anxiety neurosis

6.8 Hysterical neurosis

A number of conditions can be mistaken for mental retardation.

They are :

6.9 Early infantile autism

6.10 Attention deficit hyperactivity

6.11 Child with hearing impairment

6.12 Cultural deprivation and lack of stimulation

6.13 Specific learning disabilities

6.14 Childhood psychosis

6.15 Child with visual handicap

6.16 Child with physical handicap

7.0 MANAGEMENT AND TRAINING :

7.1 Individualized Educational Programming

Once a mentally retarded child's/ person's current level of functioning is established a programme appropriate for him/ her must be developed. In other words individualized educational programming, popularly known as IEP must be developed in order to provide appropriate education and training for the mentally retarded person the components of the IEP are :

7.1a Current level of functioning of the child in specific skills.

7.1b Annual goals

7.1c Short term objectives

7.1d Methods of training

7.1e Materials required for training

7.1f Manpower

7.1g Duration

7.1h Terminal behaviour

7.1i Evaluation for further programme planning

IEP is very much essential in training the retarded children because no two retarded children can be thought the same programme. Since each child differs from the other with regard to his/ her needs, strength and weakness of the programme developed should be tailored to suit needs of each child.

7.2 Task Analysis :

To train a person in any skill, there are certain common basic principles to be followed. Initially the skill must be broken down in to small sequential steps. This is called 'Task Analysis'. For example, a simple task 'Wearing slippers' - the major sub tasks (a) identifying one's own slippers, (b) identifying right and left slipper (c) inserting the correct foot in one slipper and (d) inserting the other foot in its slipper. Thus one has to perform all of these subtasks to complete the act of wearing slipper based on the task analysis the child should be trained.

7.3 Method :

Certain methods to be followed are :

a) Chaining, b) prompting c) shaping d) modelling and e) fading.

7.3a Chaining :

Some skills are best taught by chaining. These are skills involving several actions to be done in the right order. Chaining is simply the linking of all the sub tasks of a given task. It can be of two types, viz., forward chaining and backward chaining. when the sub tasks are taught in a sequential order starting from the first step, it is forward chaining and if the last step is taught first and proceeded from last to first step, it is backward chaining.

7.3b Prompting

Prompting is providing appropriate assistance to the child in performing in task. Here, the trainer gives some sort of indication or clue of what the child needs to do. When a child is assisted physically to perform a task, it is called physical prompting. This is reduced to verbal prompting or gestural prompting as the child learns the task.

7.3c Modelling :

In this procedure a model's act or behaviour acts as prompt for the learner. In the skill traing package, on various occasions it is suggested to have the child's brother or sister, carrying out the activity with the child, so that the child can observe and imitate.

7.3d Shaping

It is a method which helps one to learn a new task, through a series of steps. The known aspect of the task is the off point. while doing so the child is rewarded in a systematic manner for the success. For example, a child is being taught to comb hair. He might not have held the comb properly when the training started. As soon as he holds the comb properly he would be appreciated. The next day, in addition to holding, if he can direct the comb to the head he is appreciated. Here, the response which received reinforcement at one time is no longer sufficient and child had to show the next step towards the completion of the task to receive reinforcement. This is called shaping.

7.3e Fading

Systematic withdrawal of all the training procedures is known as fading. In other words ,it id the gradual removal of prompts and modeling procedures.

7.4 Motivation and reinforcement :

The procedure used to strengthen a behaviour is reinforcement . Adequate reinforcement is essential at every stage of training to motivate the child. Reinforcement can be positive or negative. For effective use of reinforcers, one has to follow certain guidelines (Narayan, et al, 1990).

1. Observe and find out the reinforcers for your child, as it varies from person to person.

2. Provide reinforcement 'immediately' following a desired behaviour.

3. If you verballly praise the child, 'mention' why you are appreciating/ reinforcing him.

4. Do you choose reinforcements that would disturb the routine.

5. Be consistent with the reinforcement following an act until the child learns.

6. If you make a promise in the form of reinforcement for the childes correct performance, keep up your promise. If the child did not fulfill the required target, do not yield and give him what is promised for the completion of the target.

7. Be specific and clear in your statements.

7.5 Parents Counselling :

Since life long adjustment is required from the parent's side, the parent guidance and counseling forms an important aspect of the management of the mentally retarded. This may help the parents to understand and to accept the child's problems and in making plans appropriate to the capability of the mentally retarded person. Counseling should be focussed on imparting in formation regarding the condition of the mentally retarded child, developing right attitudes towards the handicapped child and in educating the parents regarding their role in training. The following points are noteworthy in this contest (Madhavan,1990).

1. The child's actual condition should be explained in simple words to the parents.

2. Enough time must be taken while counseling.

3.Misleading, giving false information or building false hopes in parents must be avoided.

4. Information regarding professional help for treating associated conditions like seizures, hyperactivity, psychosis etc. must be made available to the parents.

5. Attitude such over protection ie., doing everything for the child and shielding them from any challenging situation, should be corrected as it hinders the development of whatever capacities the child may have.

6. The attitude of rejection, that is ignoring the child thinking that he is good for nothing should be changed so that the child can be helped to learn by systematic training.

7. The parents should be made aware of what they may expect of their child

8. Some patents suffer from guilt feeling assuming that they are responsible for their child's condition. It should be explained that the condition is due to causes over which parents have no direct control.

9. The counselor should explain the effectiveness and role of the parents and other family members in training a mentally retarded.

10. Some parents believe that training a mentally retarded child needs specialized skills and they may not be able to train their child. Parents should be explained that training a mentally retarded child dose not need complex skills and repeated training in simple steps, they can be taught.

11. Parents should be helped to learn the skills in training through demonstrations and observations.

7.6 Vocational Training and Job Placement :

Like any other system of education and training, the ultimate goal in training a mentally retarded person is to make him independent and earn his livelihood. Each mentally retarded person must be assessed for his readiness for work and opportunity for employment after training should be considered before training in a job

The mentally retarded person can work under three different settings.

7.6a Self employment :

There is documented evidence of motivated parents/families having taken efforts to employ the retarded persons successfully using their own resources. In such circumstances, the kind of jobs identified for them are such that they have an outlet for the product made in the immediate surroundings. Envelope making, agarbathi and candle making, running small pan shop etc. can be implemented successfully for the mentally retarded. Dairy farms, poultry and agriculture are also good examples in this regard.

7.6b Sheltered workshop :

Here, mentally retarded are trained in specific tasks matched for their ability and they work under supervision. This requires a workshop with qualified staff to train them. The products are made here on contract basis, where raw material are received and finished products returned. Sheltered workshops can be encouraged by the Government by making loans available, by providing support services such as transport, access to raw materials and through incentives by way of awards. Mild to moderate mentally retarded can be employed in sheltered workshop.

7.6c Open employment

The retarded person can be employed on certain routine repetitive jobs like any other normal person and get paid in a similar manner. This includes office boys, lift operators, restaurant table cleaners, gardeners etc. Mildly retarded persons are relatively more suitable for open employment.

7.7 Behaviour modification

As included in the definition of mental retardation, impairments in adaptive behaviour in the form of either a deficit behaviour or an excess behaviour is common among the mentally retarded individual. Some of them have undesirable and problematic bahaviours. So behaviour modification programmes are essential as part of the management package. Various behaviour modification procedures for increasing desirable behaviours and decreasing undesirable behaviours are found useful.

Procedures for Decreasinf Undesirable bahaviours

1. Restructuring the environment :

If particular problem behaviour occurs only in one environmental setting and not in others than restructuring the environment will reduce the likelihood of the occurence of the target bahaviour.

2. Extinction :

Here, the frequency of an undesirable behaviour is reduced by not presenting the immediate reinforcer of that behaviour. For example, if a child has persistent tantrums of loud screaming when asked to perform certain activity, the extinction programme for him involves, instead of abandoning tha task, non- presentation of the reinforcement ie. continuing the task.

3. Punishment :

This means introducing consequences for a behaviour that reduces the future probability of that behaviour. The common types of punishment procedures are : (a) Time out: Reward is removed during the occurence of undesirable bahaviour. If the reinforcer concerned is social attention, time out involves removal of the child from that situation. (b) Response cost: This procedure is used with individuals who are on taken programmes for learning adaptive bahaviours. When undesirable bahaviour occurs, a fixed number of tokens are deducted from what the individual has already earned. (c) Over- correction : This involves two separate procedures, viz., restitution and positive practice. If a child keeps eating indiscriminately whatever rubbish he finds on the ground, restitutional overcorrection would involve prolonged period of teeth, mouth and hand washing whenever the bahaviour occur. Positive practice which is done usually after restitution involves a prolonged practice of appropriate ways of handling rubbish: sweeping, mopping, throwing out garbage etc., (d) Restraint : Physical restraint is effective in reducing the bahaviours like physical aggression and self injurious behaviour. (e) Aversion : Life threatening or self injurious behaviours like severe head banging, biting are controlled by aversive stimuli. Faradic aversion is administered immediately following the undesirable behaviour. Contingent aversive chemical stimuli like strong pungent odours (ammonia), sour or bitter tasting substances can be presented instead of shock in young children.

Procedures for Increasing Desirable Behaviours :

People tend to continue a particular bahaviour depending upon its consequences - pleasant or unpleasant . Use of different and appropriate reinforcers have major role in increasing desirable behaviours in mentally retarded children. Four important aspects should be followed while presenting reinforcement (Madhavan,1989)

1. Contingency :

Reinforcement should be given only when the desired behaviour occurs.

2. Immediacy :

Reinforcement should be given soonafter the desired behaviour occurs.

3. Consistency :

The behaviour should be reinforced everu time it occurs.

4. Clarity :

The child should be clearly aware that reinforcement has been given.

APPENDIX - A
NORMAL MILESTONES OF DEVELOPMENT
SI.No	Milestone	Age
1	Smiles at others	4 months
2	Holds head erect	4 months
3	Puts objects into mouth	4 months
4	Rolls from back on to stomach	6 months
5	Uses whole palm to grasp	7 months
6	Makes sounds 'amma' and 'dada'	7 months
7	Sits without support	8 months
8	Responds to name	10 months
9	Crawls	10 months
10	Stand by holding on to an object	10 months
11	Holds object with thumb and index finger	10 months
12	Stands without support	10 months
13	Saya 'amma', 'akka', 'atta' meaningfully	15 months
14	Walks without support	15 months
15	Tells own name	18 months
16	Drinks by self from a glass	21 months
17	Shows body parts when named	24 months
18	Indicates toilet needs	24 months
19	Speaks in small sentences	30 months
20	Unbuttons clothes	36 months
21	Gives meaningful verbal answers to simple questions	36 months
22	Differentiates big and small	36 months
23	Identifies boy or girl	36 months
24	Can button clothes	40 months
25	Comb hair	48 months
Adapted from "Mental retardation - A manual for psychologist" by NIMH.
APPENDIX-B
FINE MOTOR SKILLS DEVELOPMENT
SI.No	Skills	Approximate age for skill acquisition
1	Maintains grasp on object	2-4 months
2	Brings hands together	2 1/2-4 months
3	Reaches for suspended swinging objects	3-5 months
4	Reaches for objects	4-5 months
5	Reaches for and picks up, using whole hand grasp (palmar grasp)	5-6 month
6	Grasps objects with both hands	5-7 months
7	Intentionally releases object from grasp	5-8 months
8	Transfers objects from one hand to the other	5-8 months
9	Grasps two objects one in each hand	7-10 months
10	Reaches for and picks up objects using thumb/ finger tips grasp	71/2-12 months
11	Picks up objects using thumbs and index finger (Pincer grasps)	7-12 months
12	Puts objects in small mouthed container	10-12 months
13	Moves objects from one container to another	16-18 months
14	Stocks vessels	15-21 months
15	Turnes knob	1 1/2-2 Yrs
16	Turns pages of a book one at a time	2-2 1/2 Yrs
17	Strings beads	2-3 1/2 Yrs
18	Unscrews and screws a jar lid	2 1/2- 3 1/2 Yrs
19	Pastes paper	2 1/2- 3 1/2 Yrs
20	Uses tongs to pick up objects	2 1/2- 3 1/2 Yrs
21	Cuts with scissors	2 1/2- 3 1/2 Yrs
22	Laces on shoes	3-4 Yrs
Adapted from the book " Skill Training in the mentally retarded persons : Fine motor skills" package for trainers by NIMH.
APPENDIX - C
GROSS MOTOR SKILLS DEVELOPMENT
SI.No	Skills	Approximate age for skill acquisition
1	Can hold head erect	0-1 Yrs
2	Can turn over	"
3	Can sit with support	"
4	Can sit without support	"
5	Can crawl	"
6	Can stand without support	"
7	Can stand without support	"
8	Can lower self from standing sitting position	"
9	Can pull self from sitting to standing position	"
10	Can walk a few step with support	"
11	Can walk independently	1-2 Yrs
12	Can sit self in a chair	"
13	Can squat and return to standing position	"
14	Can walk upstairs with aid	"
15	Can band at waist to pick up objects	"
16	Can jumb in place with both feet	2-3 Yrs
17	Can walk upstairs alternating feet	"
18	Can throw a large ball	"
19	Can run 10 feet	3-4 Yrs
20	Can kick a ball	"
21	Can use a swing	"
22	Can stand on one feet without aid for 4-8 seconds	4-5 Yrs
23	Can jump forward without falling	"
24	Can hop	5-6 Yrs
25	Can climb step/ladders 10 feet high	"
Adapted from the book " Skill Training in the mentally retarded persons : Gross motor skills" package for trainers by NIMH.