Mental retardation is defined by the AAMR as substantial limitations in present functioning; manifested by sub-average intellectual functioning, existing concurrently with limitations in two or more of the following skill areas:

1. Communication
2. Self care
3. Home living
4. Social skills
5. Community use
6. Self direction
7. Health and safety
8. Functional academics
9. Leisure
10. Work

DSM IV diagnostic criteria includes:

1. IQ of 70 or below
2. Limitations in two or more of the above skill areas
3. Onset is before age 18

Mild mental retardation IQ of 50-55 to 70-75:

• Client has the ability to learn up to a 6^th grade level and capable of social and vocational adequacy.

Moderate mental retardation IQ of 35-40 to 50-55:

• Client has the ability on 3-5 year old levels

Severe mental retardation IQ of 20-25 to 35-40:

• Client has the ability on toddler level

Profound mental retardation IQ of 20-25 or below:

• Client has the ability on an infant level (total care)

Legislation:

Public law 94-142: children are entitled to free public education in the least restrictive environment.

• Developmentally disabled assistance and the bill of rights act of 1975 (public law 94-103)- Have the right for services, treatment, and habilitation in institutions and other residential programs.

Etiology:

Includes genetic and acquired factors.

• Genetic:

Sometimes the cell division process goes wrong. Normally the chromatids separate and two new cells are formed each containing 23 chromosomes. Sometimes the duplicated chromatids do not separate resulting in one cell lacking the chromosomal material and the other cell contains both chromatids. This is called nondisjunction.

• Mosaicism - this occurs when an individual has two cell lines. One with 46 chromosomes and one with 47 chromosomes. This may result in Downs Syndrome

• Translocation- Another way in which Downs Syndrome can occur. Chromosome 21 breaks off and attaches to another chromosome

• Turner Syndrome - results from nondisjunction and one of the X-chromosomes is missing. If a sperm with a Y chromosome fertilizes the ovum containing no X chromosome, the zygote is not viable. If the ovum is fertilized by a sperm with an X chromosome the individual will end up with 45 chromosomes, will have the physical characteristics of a girl, will probably be sterile, and may be mentally retarded (20% of people with turner syndrome are mentally retarded).

• Polysomy of X - nondisjunction. There are three or more X chromosomes per cell. This condition is AKA "Super Female" because it results in the individual having female characteristics. The result is not actually accentuated femaleness but rather mental retardation and behavioral problems.

• Klinefelter Syndrome - there are multiple X and Y-chromosomes as a result of nondisjunction. The client exhibits a masculine appearance because of the Y chromosome. The problem is that at puberty female sex characteristics develop. The male gonads are underdeveloped and sterile. Mental retardation and behavioral problems usually occur.

• XYY Anomaly - can produce a dull mentality, internal and external genitalia are affected, the individual is usually tall and some studies conclude that these individuals may be aggressive.

Endocrine disorders may cause mental retardation - recall cretinism

Acquired Factors include:

• Prenatal Factors:

Infections, irradiation, toxins, drugs, and unknown causes.

• Perinatal Factors:

Prematurity, anoxia, brain damage, infection caused by intrauterine disorders, abnormal labor and delivery.

• Postnatal Factors:

Childhood disease, accidents, infections, anoxia, poisoning, hormonal problems, and environmental factors.

In infancy and early childhood developmental screening is essential in finding children at risk for mental retardation. All systems need to be assessed particularly neurological, muscular, and skeletal systems. Refer the client with two or more minor anomalies for genetic counseling.

1. Assess the infants behavior using tools like the Brazelton scale it gives clues to probable developmental outcomes.
2. Developmental skills should be assessed throughout childhood. Children who are mentally retarded may miss or be delayed in achieving stages of growth.
3. Self-care skills- the skill to eat in an acceptable manner must be developed if the child is to achieve autonomy. An assessment of eating ability is important, as is the ability to dress, toilet and personal hygiene.
4. Communication skills- the client’s motivation to master these skills must be assessed.
5. Home living skills- relate to the client’s home environment. Laundry, cooking, cleaning, budget keeping, home safety, and keeping the environment clean
6. Community skills- using available transportation, shopping centers, church, controlling self-gratification needs, obeying laws, and using appropriate social behavior.
7. Self direction skills- assess for the ability to make choices, use time and follow a daily schedule, ask for a receive help when needed, demonstrate self advocacy and problem solving abilities, complete tasks at work and home.
8. Health and safety skills- assess for the ability to fulfill health care needs. Do they know and use safety measures to use in the home and community.
9. Functional academic skills- knowledge of reading, writing, math, sexuality, and health.
10. Leisure skills- appropriate social behaviors and interactions in public settings are critical.
11. Work skills- how to seek help, keep a schedule, manage a paycheck, complete a task, work safely, groom properly, use transportation, and display social skills with co- workers.

• Dysfunctional grieving
• Ineffective family coping: compromised or disabling
• Altered family process
• Spiritual distress
• Social isolation
• Self-esteem disturbance
• Altered role performance
• Anxiety
• Self care deficit
• Impaired verbal communication
• Knowledge deficit

• Determine if the family needs counseling or if they are ready to progress to the stage of securing help for the child

• During infancy, include training for the parents to learn handling and special techniques to enhance the childs physical and mental condition

• Long-range plans should be made so that parents have a time frame to work with and helps them understand what is needed for the childs future.

• Employment needs of the parents, respite, and long-term care resources should be discussed.

• Inform the client and client’s parents of legislation

• Support of the family is crucial

• Crisis interventions may be needed for the family who has just learned of their child’s diagnosis. The family is likely to experience confusion, disorganization, helplessness, dependency, anguish and anger.

• Help the parents deal with one issue at a time. Take it one day at a time.

• Retarded children are at risk for having unmet needs (emotional, sensory, and motor) the child needs acceptance, affection and approval.

• Integrated instruction refers to teaching the child as the opportunity arises. This works best with students who are mentally retarded. An example would be to teach the child how to count change while you are shopping.

• Use positive reinforcement tools to teach- token economy, social approval and rewards.

• Is on going and aimed at the next client goal

Dual diagnosis refers to mental disorders in people with mental retardation. Little research has been conducted on dual diagnosis.

Mental retarded children, as a group are at high risk for behavioral and psychiatric disorders. In fact many are not recognized and go untreated.

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