492421598-1-MENTALLY-CHALLENGED-CHILD.pptx

MENTALLY
CHALLENGED CHILD
PRESENTED BY:
SIVABARATHY
M.SC (N) 2ND
YEAR
CON
JIPMER

INTRODUCTION
Challenged condition makes the normal function of
individual very difficult and leads to dependency.
These conditions are increasing day by day due to
changing lifestyle and complicated environment.
Challenged children is one who deviated from
normal health status either physically, mentally or
socially and requires special care, treatment and
education.

Concept of challenged:
According to WHO “the sequence of events
leading to disability and handicapped OR
challenged conditions” are as follows.
injury
impairement
disability

IMPAIREMENT:
 It is defines as any loss or abnormality of psychological, physiological
or anatomical structure or function, e.g. Loss of vision, loss of
hearing,etc
DISABILITY:
 It develops as the consequence of impairment. E.g. Loss of limbs
results in inability to walk. Disability is the inability to carry out certain
activities which are considered as normal for the age and sex.

HANDICAPED OR CHALLENGED:
 Handicap is defined as a disadvantage for a given individual resulting
from an impairment or a disability, that limits and prevents the fulfillment
of a role which is normal for that individual, depending, on age, sex,
social and cultural factors. primary handicap may lead to secondary
handicap condition e.g. Blindness leads to economical handicapped
situation.
 Mentally challenged is now used for the condition mental retardation. At
least 2 - 3 percent of Indian population are mentally handicapped in any
one form. Cognitive impairment is also used as synonym for mentally
challenged or mental retardation.

MENTALLY CHALLENGED:
 Intellectual disability (ID), also called intellectual development disorder
(IDD) and formerly known as mental retardation (MR). Mental
retardation (MR) is a developmental disability that first appears in
children under the age of 18.
 It is characterized as a level of intellectual functioning (as measured by
standard intelligence tests ) that is well below average and results in
significant limitations in the person's daily living skills (adaptive
functioning).

MENTAL RETARDATION:
 Mental retardation refers to significantly sub average general
intellectual functioning (BELOW 70) resulting in or associated
with concurrent impairments in adaptive behavior and
manifested during the developmental period.
- American association on mental deficiency,1983.

KEY WORDS:
 Significant sub average is defined as an intelligence quotient
(IQ) of 70 or below on standardized measures of intelligence.
Adaptive behavior is defined as the degrees with which the
individual meets the standards of personal independence
and social responsibility expected of his age and cultural
group. The expectations of adaptive behavior vary with the
chronological age.

The deficient in adaptive behavior
 1. During infancy and childhood
 Sensory and motor skill development
 Communication skill (including speech and language)
 Self-help skills and Socialization.
 2. During childhood and adolescent
 Application of basic academic skill to daily life activities.
 Application of appropriate reasoning and judgment in the mastery of the
environment. 
Social skill.
 3. During late adolescent
Vocational and social responsibilities and performance.
Note:- developmental period is defined as the period of time between conception
and the 18th birth day.

INCIDENCE:
 3% of the world population is estimated to be mentally retarded.
 In India 5 out of 1000 children are mentally retarded (Indian
express13th march 2011).More than 20 million children are suffering
with mental retardation.
 Mental retardation is more common in boys than girls.
 Mortality is high in severe or profound mental retardation due to
associated physical condition.
 Common in the age group of 2-3 years.
 Peak in 10–12 years of age.

CLASSIFICATION:
Intelligent quotient is the ratio between mental age (MA)
and chronological age (CA). while chronological age is
determined from the date of birth , mental age is
determined by intelligence test.

TYPES:
 Mild (Educable) 50 - 70
 Moderate (Trainable) 35 - 50
 Severe (Dependent retarded) 20 - 35
 Profound (Life support) < 20

Mild retardation ( Educable) – IQ (50%-
70%)
 85-95% of total mental retardation cases belong to mild mental
retardation.
 Environmental influences, psycho social deprivation, restrictive child
rearing practices, malnutrition, low-socio-economic class are the causes
for mild mental retardation.
 Can fully adjust educable, finds difficulty in complex ideas, drawing
generalization, can learn motor skills better than verbal skill and writing,
emotionally they are stable, overactive, temper tantrum is common, can
understand simple terms, they can be trained in special school.
 adult life most of them lead independent life in normal surroundings

Moderate retardation (Trainable) (IQ 35-50)
 10% of mental retardation cases belong to moderate mental
retardation.
 Children can be trainable, aimed at self-help skills, they can speak and
support themselves, able to perform semi-skilled or unskilled work under
supervision can learn few basic skills.
 Communication skills develop much slowly, limited progress in scholastic
work, studies up to 2nd grade, unaware of needs, have less neuro
pathological complications, partially depends on others for their care.

Severe retardation (Dependent) (IQ 20-35)
7% of total mental retardation cases, belong to severe MR.
Slow motor development in preschool years, trainable for
normal living activities, allow them to do daily living activities
under supervision, contributes partially to self-maintenance,
some children may learn social behavior , able to
communicate in simple way , engaged in limited activities,
delayed speech and communication skills.

Profound retardation (Life support) (IQ < 20)
 1-2% of mental retardation cases are profound type.
 considerable organic pathology, nervous system is noticed,
associated conditions are; blindness, deafness, seizures are
common, delayed milestones, motor impairment, totally
dependent, cannot do anything on their own.
 Death may occur due to variety of problems or
complications.

EARLY BEHAVIOURAL SIGNS
SUGGESTIVE OF MR:
Dysmorphic features (e.g. down syndrome, fragile X
syndrome).
 Irritability or unresponsiveness to contact.
 Abnormal eye contact during feeding.
 Gross motor delay.
 Decreased alertness to voice or movement.
 Language difficulties or delay
 Feeding difficulties.

DIAGNOSIS:
 The diagnosis of mental retardation is usually made after a period of
suspicion by professionals or family members that the child’s
developmental progress is delayed.
 In some cases it is conformed at birth because of recognition of
district syndrome.
 Routine developmental screening can assist in early identification.
 Multidisciplinary evaluation should be individually tailored to the
child. A team of professionals like pediatric neurologist,
developmental pediatrician, psychologist, social scientist, speech
therapist, physical therapist, special educator, social worker and
nurse will evaluate the child.
 Complete history is collected from family members and care takers.

Mental history
 Physical examination to exclude physical illness.
Neurological assessment
 Assessment of mile stones like intellectual levels, cognitive
ability, language pattern and communication skills, hearing,
cognitive behavior.
 Urine and blood examination for metabolic disorders.
Hormonal studies- T3, T4, TSH when cretinism is suspected.
Culture for cytogenic and biochemical studies.
 EEG to exclude seizures.
MRI, CT scan to study the structural abnormality of brain for
example tuberous sclerosis.

Antibodies for diagnosing infections, LFT in Wilson’s
disease.
 Sensory test – assessment for vision, hearing.
 Amniocentesis for pregnant mothers to detect
chromosomal abnormalities, chorionic villi sampling,
chromosomal analysis.
 Education evaluation- reading, writing, regularity in
schooling, living learning skills, daily living skills, social
abilities.

Psychological investigation includes Stanford Binet
intelligence tests (mental abilities) 2 years and more.
Wechler’s intelligence scale for children WISC
(above 6 years)
Through the psychological testing the mental age of
the child estimated. The intelligence quotient is then
determined using the formula.

Treatment modalities for MR
 Behavior management.
 Environmental supervision.
 Monitoring the child’s developmental needs and problems.
 Programs that maximize speech, language, cognitive, psychomotor, social, self-
care, and occupational skills.
 Ongoing evaluation for overlapping psychiatric disorders, such as depression,
bipolar disorder, and ADHD.
 Family therapy to help parents develop coping skills and deal with guilt or anger.
 Early intervention programs for children younger than age 3 with mental retardation
 Provide day schools to train the child in basic skills, such as bathing and feeding.
 Vocational training.

 Preconception:
Genetic counseling,
Immunization for maternal rubella.
 Blood tests for marriage licenses can identify the
presence of venereal disease.
Adequate maternal nutrition can lay a sound
metabolic foundation for later childbearing.
Family planning in terms of size, appropriate
spacing and age of parents can also affect a
variety of specific causal agents.

PRIMARY PREVENTION ……
During gestation:
 Prenatal care:
 Adequate nutrition, fetal monitoring and protection from
diseases.
 Avoidance of teratogenic substances like exposure to
radiation and consumption of alcohol and drugs.
 Analysis of fetus for possible genetic disorder:

 At delivery:
 Delivery conducted by expert doctors and staff, especially in cases
of high risk pregnancy.
 Apgar scoring done at 1 to 5 minutes after the birth of the child.
 Injection of gamma globulin, to protect the child not to get Rh
incompatability.
 Childhood:
 Proper nutrition throughout the developmental period and
particularly during the first 6 months after birth.
 Dietary restriction for specific metabolic disorders until no longer
needed.
 Avoidance of hazards in the child’s environment to avoid brain injury
from causes such as lead poisoning, ingestion of chemicals, or
accidents.

 SECONDARY PREVENTION:
Early detection and treatment of preventable disorders. For example
phenylketonuria, hypothyroidism can be effectively treated at an early
stage by dietary control or hormone replacement therapy.
 Early recognition of presence of mental retardation. A delay in
diagnosis may cause unfortunate delay in rehabilitation.
 Psychiatric treatment for emotional and behavioral difficulties.
 TERTIARY PREVENTION……
 This includes rehabilitation in vocational, physical and social areas
according to the level of challenged.
 Rehabilitation is aimed at reducing disability and providing optimal
functioning in a child with mental retardation.

CARE AND REHABILITATION OF MR
 THE PREVENTION AND EARLY DETECTION OF MENTALLY HANDICAPS.
 Regular assessment of the mentally retarded persons attainments and disabilities.
 Advice, support, and practical measures for families.
 Provision for education, training, occupation, or work appropriate for each handicapped
person.
 Housing and social support to enable self-care.
 Medical, nursing, Psychiatric and psychological services those who require them as
outpatients, day patients or inpatients.
 GENERAL PROVISIONS……
 The family doctor and pediatrician are mainly responsible for early detection and
assessment of mental retardation
 The team providing continuing health care also includes psychologists, speech therapists,
nurses, occupational therapists and physiotherapists.

 Mildly retarded….
 A few mildly retarded children require fostering, boarding schools placement or residential care, but
usually specialist services are not required.
 Mildly retarded adults may need help with housing, employment or with the special problems of old
age.
 Severely retarded…..
 In case of severely retarded may require special services throughout their lives, which may include a
setting services, day respite during school holidays, or overnight stays in a foster family or residential
care.
 The main principle now guiding the provision of resources is that the retarded person should be use the
usual community services rather than to provide specialist segregate services.
 Education and training…….
 The aim is that as many mentally retarded children as possible are educated in ordinary schools either
in normal classes or in special classes.
 There is now an increasing use of more specialists teaching and a variety of innovative procedures for
teaching language and other methods of communication.
 Before leaving school, these children require reassessment and vocational guidance.

HINTS FOR SUCCESSFUL TRAINING…
 Divide each training activity into small steps and demonstrate.
 Give repeated training in each activity.
 Give the training regularly and systematically.
 Starts the training with what the child already knows and then proceed to the skill that needs to
be trained. By this the child will have a feeling of success and achievement.
 Rewards his efforts even if the child attains near success.
 Use the training material which is appropriate, attractive and locally available.
 Remember children will learn better from children of the same age.
 Remember there is no age limit for training a mentally retarded person.
 Assess the child periodically preferably once in a four or six months.
 Remember a mentally retarded child learn very slowly. Tell the parents not to be dejected at
the slow progress, nor feel threatened by the child failure.

 VOCATIONAL TRAINING………
 Vocational activities include in vocational training are work
preparation, selective placement, post placement and follow up.
For example:- MITRA special school and vocational training center for
the mentally retarded , Bengaluru, Karnataka.
HELP FOR FAMILIES……..
 Help for families is needed from the time that the diagnosis is first made.
 When the child starts school the parents should not only be kept
informed about this progress, but should feel involved in the planning
and provision of care.
 Families are likely to need extra help when their child is approaching
puberty or leaving school.

Stages in parent counseling…..
 Stage-I:- impart information regarding condition of the mentally retarded child.
Avoid giving misleading information or building false hopes in the parents.
 Stage-II:- help the parents develop right attitude towards their mentally retarded
child (to prevent overprotection, rejection, pushing the child too hard). Handle guilty
feelings in parents.
 Stage-III:- create awareness in parents regarding their role in training the child.

Can I ask some
questions…..?

 Is mental retardation same as mental illness?
 No , mentally retarded persons are not mentally ill. The mentally retarded
persons are just slow in their development.
 Is mental retardation curable?
 No. mental retardation is a condition which cannot be curable. But timely and
appropriate intervention can help mentally retarded person learn several skills.
 Is it true that the mentally retarded persons cannot be taught anything?
 No. mentally retarded persons can be taught many things, but they need to
be trained systematically. They can perform many jobs under supervision.
 Can marriage solve the problems of mentally retardation?
 No. many people think that after marriage, the mentally retarded person will
become active and responsible or sexual satisfaction will cure the person. That is
not so. Marriage will only further complicate the problem. When it is known that a
mentally retarded person cannot be totally independent, it will not be possible to
look after his family.

NURSING MANAGEMENT
 Assessment of early infant behavior for cognitive disability include non-responsiveness to
contact, poor eye contact and during feeding, slow feeding, diminished spontaneous
activity, decreased responsiveness to surroundings, decreased alertness to voice or
movement, and irritability.
 Documentation of daily living skills.
 A careful family assessment for information on The family’s response to the child.
 Presence of other members with impaired cognition in the family.
 Degree of independence encouraged at home.
 Stability of the family unit
 Early intervention programs are essential to maximize the potential development.
 The nurse can participate in programs that teach infant stimulation, activities of daily living
and independent self-care skills. A successful technique in treatment of the mentally
retarded is called operant conditioning.
 In addition learning social skills and adaptive behavior assists the child in building a positive
self-image. For older children and adolescent assistance is needed to prepare them for a
productive work life.

 Determine the child’s strengths & abilities & develop a plan of care to maintain &
enhance capabilities.
 Monitor the child’s developmental levels & initiate supportive interventions, such
as speech, language, or occupational skills as needed.
 Teach him about natural & normal feelings & emotions.
 Provide for his safety needs. Prevent self-injury. Be prepared to intervene if self-
injury occurs. Monitor the child for physical or emotional distress.
 Modify his behavior by having him redirect his energy.
 Teach the child adaptive skills, such as eating, dressing, grooming & toileting.
Demonstrate & help him practice self-care skills.
 Work to increase his compliance with conventional social norms & behaviors.
Maintain a consistent & supervised environment.
 Maintain adequate environmental stimulation.
 Set supportive limits on activities.
 Work to maintain & enhance his positive feelings about self & daily
accomplishments.

INTERVENTION:
 The long term goals for these children are highly
individualized and are dependent on the level of mental
retardation . parents should be involved in establishing
realistic goals for their child. Some of these goals can be:
 The child dresses himself
 The child maintains continence of stool and urine
 The child demonstrate acceptable social behavior
 The adolescent participates in a structured work
program.

PROGNOSIS:
The prognosis for children with metal retardation has
improved & institutional care is no longer
recommended.
 These children are mainstreamed whenever feasible &
are taught survival skills.
A multidimensional orientation is used when working
with these children, considering their psychological,
cognitive, social & emotional development.

THEORY APPLICATION:
 MASLOW HIERARCHY THEORY:

JOURNAL REFERENCE:
TITLE: Social development of children with mental retardation.
ABSTRACT:
Social development of children with mental retardation has
implication for prognosis. The present study evaluated
whether the social maturity scale done can reflect on the
social maturity, intellectual level and consequent adjustment
in family and society of children with mental retardation.
Materials and methods:
Thirty five retarded children were administered vineland social
maturity scale and Stanford Binet intelligence scale.

 RESULTS:
It was found that there was significant relationship between
the measures of social maturity scale and the IQ of the
subjects. Further it was found that with increasing severity of
retardation, social development also decreases and age does
not have any effect or social development.
 Conclusion:
Social quotient increases from profound to mild level of
retardation.

Reference:
1. Marlow R, Redding A. Marlow’s textbook of pediatric nursing.
Elseiver south Asia edition. 6th
2013.
2. Datta p.A textbook of pediatric nursing, jaypee brothers medical
publishers ltd.2013.
3. Hockenberry J. Wilson P, Wong’s essential of pediatric nursing
elseiver south asia ed. 8th
.2012.
4. Gupta P. textbook of paediatrics. CSP publishers. New Delhi. 2013.
5. Pancahli P. textbook paediatric nursing. New delhi. Paras Medical
Publication. 2016.

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