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Mental Sub normality/Intellectual Disability in Childhood�BY

Prof Edwin E. Eseigbe

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OUTLINE

Objectives
Introduction
Causes
Pathogenesis
Clinical features
Evaluation
Diagnosis
Categories
Differential diagnosis
Management
Prevention
Conclusion

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OBJECTIVES

Basic and current medical knowledge of mental subnormalities in childhood
To apply acquired knowledge in the identification and management of mental subnormalities in childhood

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MENTAL SUBNORMALITIES

So much controversy about terminology

Stigmatization
Gaps in terminology
Limits achievements of the child
Precludes assistance to the child
Intellectual disability (ID)-New terminology in DSM 5
Gaps with the ID terminology
Synonymous with other existing conditions e.g. Learning disability

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MENTAL SUBNORMALITIES

Definition
Disorder with onset in the developmental period
Intellectual deficits
Difficulties in communication, self-care, home living, social/interpersonal skills, self direction, academics , safety and health

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MENTAL SUBNORMALITIES

Definition
Sub-average general intellectual functioning, existing concurrently with deficits in adaptive behavior and social skills in the developmental period, adversely affects the child’s educational performance(IDEA, AAIDD)
Before 18 years,
Age of onset afterwards condition regarded as Dementia

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SIGNIFICANT IMPAIRMENT IN INTELLECTUAL FUNCTIONING

Test of Intelligence score less than 2 SD of the mean
Scores less than 70 indicate impairment
Consideration of statistical variables increases the number of those assumed to have impairment
Children with impairment show variable pattern of strengths and weaknesses

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SIGNIFICANT IMPAIRMENT IN ADAPTIVE BEHAVIOUR

Degree that cognitive function impairs daily function
Adaptive behaviour addresses 3 broad sets of skills
Conceptual skills: language , reading, writing, money concepts, and self direction
Social skills: Interpersonal skills, personal responsibility, self-esteem, gullibility, naiveté, ability to follow rules, obey laws , avoid victimization.
Practical skills: Performance of activities of daily living, instrumental activities of daily living (housework, managing money, taking medication, shopping, using the telephone), occupational skills, maintenance of a safe environment.

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SIGNIFICANT IMPAIRMENT IN ADAPTIVE BEHAVIOUR

Significant delay in 1 of the 3 areas need to be present

However, this requirement for adaptive behaviour deficit is controversial

-How relevant is this measure in the construct of Intellectual Disability?

-Want should one measure?

-The enumerated domains have not been validated with research

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MENTAL RETARDATION

2.5% of the general population has mental retardation
Boy:girl,1.5-2:1
Generally classified as mild, moderate and severe using Intelligence Quotient (IQ) test scores

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CAUSES

Chromosomal: trisomies 13,18, 21
Genetic syndromes-Fragile X, Prader-Willi
Developmental brain anomalies-lissencephaly
Inborn errors of metabolism-Phenylketonuria
Congenital infections-TORCHES, HIV
Peri-natal causes-IVH, PVL, HIE, Meningitis
Post natal causes-trauma, infections,
Endocrine – hypothyroidism
Familial retardation
Nutritional

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PATHOGENESIS

Limited knowledge
Brains appear normal in neuropathology settings
Pathological findings:
Microcephaly
Gray matter heterotopias,
Dysgenesis of dendritic spines or cortical pyramidal neurons

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EVALUATION: GENERAL

Surveillance

Systematic ongoing collection, collation, and analysis of data and the timely dissemination of information to those who need to know so that action can be taken

Screening

Looking for evidence of disease in an asymptomatic population

Diagnosis

Confirmation of disease, particularly in a symptomatic population

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Surveillance

Passive: Based on reports submitted by health facilities
Active: Continuous pre-organized process
Sentinel: Monitoring of rate of occurrence of specific diseases by a group of health workers

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Screening

Recommendations

All children receive screening for developmental delays at their 9-,18-,and 24- or 30-month well-child visits

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CLINICAL FEATURES

Dysmorphism
Delayed achievement of developmental milestones
Dysfunctions-seizures, cerebral palsy, autism spectrum disorder
Feeding difficulties
Academic failure

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CLINICAL FEATURES: HISTORY

Biodata - cultural differences ,religion, age
Complaints - surveillance history from parents, schools . usually communication, behavioral, social, feeding issues
Past medical history - recurrent ARI, GIT issues, PICA , allergies
Pregnancy history:- assisted conception, maternal malnutrition, drug usage, PIH and diabetes, prenatal asphyxia, neonatal jaundice.
Nutritional history :- food aversiveness, food selectivity,

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CLINICAL FEATURES: HISTORY

Developmental history
Regressions, motor skills, social skills, behaviour, play skills, adaptive skills
Academic history :- multiple change of schools, history from teachers , therapist, poor academic achievements
Family and social history:- interaction in family, family inclusiveness, history from siblings and impact, family disunity, family dynamics, no of people in the family and finances available, parental social economic level.

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CHARACTERISTICS OF INTELLECTUAL DISABILITY

Characteristics	Features
General cognition	Slow learners
Memory	Deficient in relating information to new situation
Attention	Does not understand or filter information
Adaptive skills	Difficulty in learning and applying skills
Self regulation	Poor organizational ability
Speech and language	Limited verbal and non verbal communication
Motivation	Lack motivation
Academic achievement	Poor academic achievement
Physical characteristics	May exhibit co morbidities

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CLINICAL FEATURES: PHYSICAL EXAMINATION

Dysmorphic features
Abnormal smell
Abnormalities on systemic examination

CNS: Poor cognition and executive function, impaired speech and language development, abnormal cranial nerves, poor or absent tone and reflexes

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ASSESSMENT TOOLS

Assessment Tools include:

Draw-A-Man test
Bayley Scales of Infant Development(BSID-II)
Wechsler Scales
Vineland Adaptive Behavior Scale (VABS)
Malawi Development Assessment Tool(MDAT)
World Health Organization Ten Questions
SMAT Score
Ibadan Simplified Developmental Assessment Tool

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INVESTIGATIONS

Neuro imaging studies
Genetic screening/Testing
Biochemical assays
Hormonal assays
Drug levels

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DIAGNOSIS-CATEGORIES

Mild-50 to 69
Moderate-35 to 49
Severe-20 to 34
Profound- Below 20

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Classification of Intellectual Disability and Severity of Disability

Level of Intellectual Disability	IQ Range	Approximate mental age in adulthood	% of persons with intellectual disability at this level
Mild	50-69	8 years	85
Moderate	36-51	5 years	10
Severe	20-35	3 years	3.5
Profound	<20	<3 years	1.5

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DIFFERENTIAL DIAGNOSIS

Cerebral palsy
Autism spectrum disorder (ASD)
Learning disability
Communication disorders
Attention Deficit Hyperactivity Disorder (ADHD)

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MANAGEMENT

Early identification is vital
Multidisciplinary approach
Specific treatment e.g. Dietary restriction in Phenylketonuria
Addressing confounding issues
Stigma and Discrimination
Cultural influence
Limited resources for treatment

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PREVENTION

Primary prevention
Promote healthy lifestyle
Avoid contact with the disease

Secondary prevention
Early/prompt diagnosis
Appropriate and adequate treatment

Tertiary prevention
Reduce disability
Overcome handicap

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CONCLUSION

The incidence and management of intellectual disability in childhood are increasingly challenging particularly in LMICs where these are associated with poor health and social outcomes. Strategic interventions to limit the impact of intellectual disability are needed to optimise childhood growth and development.

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THANK YOU FOR LISTENING

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REFERENCES

Contact Prof E. E. Eseigbe: eeeseigbe@yahoo.com