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.

disability

impairement

injury
 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.