Psychiatry

Mental retardation and learning disorders

Dr. Yu
3rd shifting/October 22, 08
Juday and forever friends

MENTAL RETARDATION Weschler Test

IQ scores fairly stable
Philippine Stats: DepEd Individually administered tests
Children with special needs 156,270 WISC IV (age 6-16 yrs)
are enrolled in schools WAIS III (age 16-89 yrs)
Mentally gifted/fast learners 77,152 WPPSI-R (age 2.5-7 yrs)
(G/FL)
Are children with disabilities 79,118 Adaptive Functioning Tests
Mentally retarded 12,456 a. Vineland Adaptive Behavior Scale
4yrs and 11mos old
What is IQ? semi-structured interview involving parents,
Developed by French psychologist Alfred Binet in 1904 teachers, and caregivers
“quotient” refers to Binet’s definition of IQ communications, daily living skills, socialization
___mental age___ x100 and motor skills
chronological age b. Woodcock-Johnson Scale of Independent Behavior
c. American Association on Mental Retardation Adaptive
Modern IQ tests Behavior Scale
deviation IQ
refernced to other people Traditionally, mental retardation is known as
a. Cretin
Mental Retardation oldest term, coined from a French word
Not a disease people with significant intellectual or
Result of a pathological process in the brain developmental disabilities were “still human”
Limitations in intellectual and adaptive function and and deserved to be treated with basic
Alternative terms: human dignity
Developmental delay b. Idiot
imply that appropriate intervention will improve from Greek Word idiotos, meaning unfit for
or completely eliminate the condition public life
“catching up” c. Imbecile
a term for a pattern of persistently slow learning of basic indicated an intellectual disability less extreme
motor and language skills (milestones) during childhood, than idiocy and not neccesaarily inherited.
and a significantly below-normal intellectual capacity as d. Moron
an adult. defined by the American Association for the
Mental impairment - state of arrested or incomplete Study of the Feeble-minded in 1910
development of mind which includes: adult with a mental age between 8 and 12
significant/severe impairment of intelligence and
social functioning and is associated with Degrees of severity
abnormally aggressive or seriously irresponsible Moron - Mild
conduct on the part of the person concerned. Imbecile - Moderate
(mental health act 1983) - Severe
a disability characterized by significant limitations both in Idiot - Profound
intellectual functioning and in adaptive behavior as
expressed in conceptual, social and practical adaptive Mild Mental Retardation
skills. This disability originates before the age of 18. IQ range from 50-55 to 70
(American Association on Mental Retardation, 2002) 85% of mentally retarded people
identified in Grade 1 or 2
DSM-IV TR definition specific causes unidentified
IQ (as measured by standard tests) is subaverage (<70 Prognosis: can be independent with appropriate
or <2SD from mean) and a measure of adaptive function support
in at least 2 areas is deficient teachable
Communication Self-care
Home living Social/interpersonal Moderate Mental Retardation
Self-direction Works IQ range: 35-40 to 50-55
Leisure Health and safety 10% of MR
Funcational academic skill Early childhood: adequate language skills
Use of community resources School age: poor academic achievement
Teens: poor socialization
Intelligence Tests Adult: semiskilled work with supervision
trainable
Stanford-Binet Intelligence Scale
comprises 15 subsets Severe Mental Retardation
assess 4 areas of intelligence: verbal abilities, IQ range from 20-25 to 35-40
abstract/visual thinking, quatitative reasoning, short- 4% of MR
term memory can count and recognize words that are needed for
functioning
cause: usually identifiable
 adults: supervised living situations (home)
LEARNING DISORDERS
Profound Mental Retardation
IQ below 20 or 25 Case Study
1-2% of MR Sarah hates reading aloud in class. She’s never been a good
cause: identifiable reader, and even when she recognizes the words on the page,
children: self-care skills and may learn to communicate she seems to have trouble reading them correctly. School’s
needs with training never been her favorite place anyways because her teachers
always complain of her writing and her spelling. She often
Epidemiology gets discouraged, thinking that she’s not as smart as other
US: 1% of the population students.
Highest incidence: school-aged (10-14y/o) Fortunately, Sarah has discovered she has talents that other
1.5x more common in men than women don’t. She’s great at dreaming up costume and scenery ideas
if sever or profound: higher mortality due to in drama club, and she’s one of the best artists in her school.
complications of associated physical disorders Sometimes, she wonders how she can do so well in some
areas of her life and so poorly in others. What Sarah, her
Co-morbidity parents, and her teachers don’t realize is that Sarah has a
2/3 of children and adults have comorbid mental learning disorder.
disorders
correlates with severity of MR Learning Disorder
mood disorders, schizophrenia, autistic disorder and neurologic in origin, and it impedes a person;s ability to
pervasive dev d/o store, process and/or produce information
neurologic disorders (seizures) clinical feature of a learning disorder is the lack of normal
genetic syndromes developmental skill expected in a child, either cognitive
Fragile X, Prader-Willi and Down Syndrome or linguistic
measured by individually administered standardized tests
Etiology substantially below that expected of a person’s
genetic chronological age, measured intelligence and age-
acquired appropriate education
environmental/social significantly interferes with academic achievement or
activities of daily living requiring the specific ability
Genetic causes of MR (reading, writing, matematics)
abnormalities in autuosomal or sex chromosomes the difficulty is in excess of those usually associated with
from advanced maternal or paternal age a sensory deficit (if present)
X-ray radiation
Down syndrome Evaluation
Fragile-X syndrome History – ask for past medical, family, maternal, and
Prader-Willi syndrome developmental history
Cri-du-Chat syndrome Do complete physical examination, neurologic and
MSUD (Maple syrup urine dse) developmental assessment
Take note of any associated medical condition, and treat
Acquired and environmental factors as necessary (eg ADHD)
maternal chronic illness (diabetes, hypertension) Refer to specialists once diagnosis is made
infection (TORCHSS, AIDS) Work up patients as needed
narcotic and alcoholic substance (ab)use Hearing tests
perinatal period (prematurity, LBW, ICH) Eye examination
aquired childhood disorders (encephalitis, meningitis,
head trauma) Reading Disorder
aka
Environmental/Social Factors dyslexia
deprivation of nutrition and nurturance word blindness
family instability reading backwards
children of psychotic patients learning disability
impaired ability to recognize words
Differential Diagnosis slow and inaccurate reading
learning disorders poor comprehension
pervasive developmental disorders
Epidemiology
Treatment 1 out of 20 school children
Primary prevention – gentic counseling and good prenatal half of those receiving special education
care boys>girls
Secondary prevention – treat the comorbid condition increased risk of comorbidity
Tertiary prevention ADHD 25% cases
behavioral, cognitive, psychodynamic therapies Disruptive behavior disorders
Education for child and family Depressive disorders
Pharmacology for co-morbidities
Clinical Features
Course and prognosis identified by age 7
usually the underlying intellectual impairment does not usually bright kids who excel in non-reading activities
improve (arts, drama, music, sports) “bibo kids”
adaptive skills can be enriched by a supportive falling behind in subjects that require reading
environment dislikes and avoids reading and writing
limited by existing co-morbidities relies heavily on memorization
 patient complains of seeing words upside down, or
dancing on the page
makes errors in oral reading
omissions/additions Epidemiology
distortion of words 6.4% of school-aged children
reads slowly with minimal _____ girls>boys
associated language difficulties may occur in isolation or in conjunction with
impaired sound discrimination 56% of children with RD
difficulty sequencing words disorders of written expressions
“zones out” during study session expressive language disorder
tends to be angry and depressed and exhibit low self- developmental coordination disorder
esteem
Etiology
Treatment multifactorial
do not aggravate situation arithmetic skills depend more on the amount and quality
tell teachers not to call the patient in front of the class to of instruction
read
advise an after-school reading program or a reading tutor Clinical Features
use of recorders to take note of assignments detected duing the 2nd and 3rd grade
giving exams verbally poor achievement in the following skills
perceptual
Writing Disorders mathematical
aka linguistic – word problems into numbers
dysgraphia attentional – ADHD
spelling dyslexia
spelling disorder Treatment
writing is a complex task that requires integration of children with MD usually perceive the subject as
cognition, language and motor skills threatening and intimidating
children experience this disorder as “thoughts that move in school, advixe teachers regarding the student
faster than their hands can translate them onto papers” they must not be asked to answer questions in
class
Epidemiology do not allow other students to correct papers of
4% of school-aged children those with MD
boys>girls giving them more time to solve problems or
comorbidity allowing them to solve fewer problems
reading disorder at home, parents should be advised to be non-
ADHD, oppositional ??? disorder judgmental and make mathematics fun whenever
Language disorder possible
Depression and poor self-esteem supervised/tutorial practice in solving
mathematical problems
Etiology teach mathematics through real-life situation
- anatomic allowing the use of calculators or other tools to
injury to or vascular abnormalities in the solve problems
posterior corpus callosum or superior temporal for the child
gyrus explain that mathematics is only 1 of the many
- other medical condition forms of intelligence and reassure them that
epilepsy they are competent individuals
encourage them to have a degree of optimism
Clinical Features towards the subject, let them perceive this as a
Diagnosis made during the second year of elementary grade challenge to conquer
(script na kasi magsulat)
letter reversal (b-d) (p-q) HOW TO KNOW IF A CHILD HAS A LEARNING
letter inversion (m-w) DISORDER
transpositions (felt-left) Ages 3 to 5 does your preschooler…
word reversal (was-saw) seem uninterested in playing games with language
number reversal (14-41) sounds, such as repetition and rhyming?
Have trouble learning nursery rhymes, such as “Humpty
Treatment Dumpty” or “Jack and Jill”?
use of computers with spell check and grammar check Frequently mispronounce words and persist in using baby
use of programs that translate voice to typewritten words talk?
assistance with note taking (buddy system, prepared Fail to recognize the letters in his or her name?
notes) Have difficulty remembering the names of letters,
give ample time to finish writing essays numbers or days of the week?
allow to use scribes if output is needed
using other methods to grade student (eg. Recitation) Ages 5 to 6 does your kindergartner…
fail to recognize and write letters, write his or her name
Mathematics Disorder or use invented spelling for words?
aka Have trouble breaking spoken words into syllables, such
dyscalculia as cowboy into cow and boy?
congenital arithmetic disorder Still have trouble recognizing words that rhyme, such as
Gerstmann syndrome cat and bat?
Have difficulty remembering numbers Fail to connect letters and sounds? (ask your child: what
Slow, inaccurate in computation does the letter b sound like?)
 Fail to recognize phonemes? (ask your child: what starts
with the same saound as cat--dog, ma or car?)

Ages 6 to 7 does your first-grader…

still have difficulty recognizing and manipulating
phonemes?
Fail to read common one-syllable words, such as mat or
top?
Make reading errors that suggest a failure to connect
sounds and letters, such as big for goat?
Fail to recognize common, irregularly spelled words, such
as said, where and two?
Complain about how hard reading is and refuse to do it?

Age 7 and older does your child

mispronounce long or complicated words saying
“amulium” instead of “aluminum”?
confuse words that sound alike, such as tornado for
volcano, or lotion for ocean?
Speak haltingly and overuse vague word such as stuff or
things?
Have trouble memorizing dates, names, and telephone
numbers?
Have trouble reading small function words, such as that,
an and in?
Guess wildly when reading multisyllabic words instead of
sound them out?
Skip parts of words, reading conible instead of
convertible, for example?
When reading aloud often substitute easy words for hard
ones, such as car for automobile?
Spell terribly and have messy handwriting?
Have trouble completing out homework or finishing tests
on time?
Have a deep fear of reading aloud?