This is an informative chapter about mental retardation. None of this information in here or other chapters can be used to diagnose people. Only psychiatry professions are obligated to diagnose. Psychopathology chapters are review and summary of Textbook “David H. Barlow, V. Mark Durand (2014) Abnormal Psychology: An Integrative Approach” and lecture notes.

Mental Retardation

A usually chronic and irreversible condition whose diagnosis is based on an IQ of 70 or below and problems with daily functioning that begin before the age of 18.

IQ must be below 70.
Problems with daily functioning due to low intelligence.
Disorder must set before the age of 18.

Mild Mental Retardation (IQ: 50-70) “Educable” 85%.
Moderate Mental Retardation (IQ: 35-50) “Trainable” 10%.
Severe Mental Retardation (IQ: 20-35) 3-4%.
Profound Mental Retardation (IQ: <20) 1-2%

The line between normal ability and retardation depends on the circumstances of testing and the demands of the individual`s life situation.

Measuring Intelligence

Traditional IQ tests developed by Alfred Binet in 1905

Problem areas:

1.Sociocultural factors;

Tests are developed on white middle-class children, so they may be invalid for diagnosing mental retardation in members of groups with different cultural backgrounds.

2.Measurement of relevant abilities;

Tests were developed to measure "the school performance" not "the real world performance".

3.Physical and emotional factors;

Individuals with mental retardation may also suffer from a variety of physical and emotional problems, and these may interfere with the performance on tests.

Mental Retardation Types

1.Due to genetic factors (25% of all);

Down Syndrome:

Most common genetic cause (1:1000 births).
Moderate mental retardation.
A typical face and often short.
Good-natured, happy, affectionate, playful, socially well adjusted.
Develop Alzheimer's disease early (around 40).
Extra chromosome 21 (trisomy 21).
The older the mother the higher the risk.
After mid-30s higher risk.
20 yrs: 0.58:1000 live births.
49 yrs: 87.93:1000 live births.
In men after mid 50s higher risk.
Test in pregnancy.

Phenylketonuria (PKU):

1:15 0000 live births.
Severe mental retardation.
No talk, walk.
Unpredictable, hyperactive, unresponsive.
A recessive gene.
Low level of Phenylalanine oxidase (phenylalanine >>>> phenyl pyruvic acid)
Pehnylpyruvic acid destroys the brain.

Turner's Syndrome:

Women`s sex chromosome is X instead of XX.
Lack of secondary sex characteristics.
Sometimes mental retardation.

Klinefelter`s Syndrome:

Limited to men.
XXY or XXXY instead of XY.
Retardation in half of the cases.

Cretinism:

Hypothyroidism.
Dwarfism.
Low levels of thyroxin.
A recessive gene.

2. Due to physical factors in the environment;

Infections, drugs, exposure to lead, temperature, nutrition, and injuries during pregnancy, the birth process, infancy.

Fetal Alcohol Syndrome:

Alcohol use during pregnancy.
Mild to severe retardation.
Attentional difficulties and hyperactivity.
Physical abnormalities (microencephaly etc.).

Rubella (German Measles):

Mother ill during pregnancy.
In the first month >>> 50% retardation.
Mild to severe retardation.
Inflammation of the brain and degeneration of the fetus.

Lead Poisoning:

Exposure to lead in pregnancy and early in life
Mild to Moderate retardation.

Diet:

Low protein and calories.

3.Due to psychosocial factors;

Limited psychosocial environments:

Advantaged homes vs. disadvantaged homes

Language habits:

Restricted language patterns cause low intellectual functioning.

Child-rearing style:

More authoritarian leads fewer opportunities for self-exploration.

Motivation:

“Don`t try, you cannot do it!”

Schooling:

“Nature of teaching and the social interaction.”

Poor physical and medical care:

Case Work: ROCKING AND READING

Twenty-two-year-old Betsy was referred for evaluation by the staff of her group home. She had been placed in the group home some 3 months previously, following court-ordered "deinstitutionalization" from a large residential facility for the retarded.

The evaluation was requested because Betsy "didn't fit in" with other patients and had developed some problem behaviors, particularly aggression directed toward herself and, less commonly, toward others.

Unlike other patients in the group home, she tended to "stay to herself' and had essentially no peer relations, although she did respond positively to some staff members.

Her self-abusive and aggressive behaviors usually were triggered by changes made in her routine. Self-abusive behavior consisted of repeated pounding of her legs and biting of her hand.

Betsy had been placed in residential treatment when she was age 4 and had remained in some kind of residential setting ever since. Her parents had both died, and she had no contact with her only sibling.

At the time of her transfer to the group home, she was reported to have had several abnormal electroencephalograms, but no seizures or other medical problems had been noted. When last given psychological tests, she achieved a full-scale IQ of 55, with comparable deficits in adaptive behaviors.

During the evaluation, Betsy spends much of her time reading a children's book she discovered in the waiting room. Her voice is flat and monotonic. She is unable to respond to any questions about the book she is reading and reacts to interruptions of her ongoing activity by pounding her legs with her fist.

She rocks back and forth continually during the interview. She makes eye contact with the examiner initially but otherwise seems blind to everyone around her. She neither initiates activities, imitates the play of the examiner, nor responds to attempts to interest her in alternative activities, such as playing with a doll.

From time to time she repeats a single phrase in a monotonic voice, "Blum, Blum." Physical examination reveals extensive bruises covering most of her lower extremities.

Betsy was the product of a normal pregnancy, labor, and delivery. She was noted to have been an unusually easy baby. Her parents had first become concerned when she failed to speak by age 2. Motor milestones were delayed.

Her parents initially thought that she might be deaf, but this was obviously not the case, as she responded with panic to the sound of a vacuum cleaner.

As a young child, Betsy had been observed to "live in her own world," had not formed attachments to her parents, had idiosyncratic responses to some sounds, and always became extremely upset when there were changes in her environment. By age 4, Betsy was still not speaking, and placement in the state institution was recommended following a diagnosis of Childhood Schizophrenia.

In the year after her placement, Betsy began speaking. However, she did not typically use speech for communication; instead, she merely repeated phrases over and over.

She had an unusual ability to memorize and became fascinated with reading, even though she appeared not to comprehend anything she read. She exhibited a variety of stereotyped behaviors, including body rocking and headbanging, requiring a great deal of attention from the staff.

Betsy has long-standing problems, including impairment in social interaction (lack of awareness of others and gross impairment in peer relations). Although she has some speech, it is markedly abnormal in its production (monotonic) and in its form and content (she repeats the same phrases over and over).

She exhibits stereotyped behaviors (rocking) and a markedly restricted range of interests. All of these, beginning in early childhood, establish the diagnosis of Autistic Disorder.

Although some cases of Autistic Disorder are associated with normal, or more rarely, high IQ, this case illustrates its frequent coexistence with Mild Mental Retardation.

At the time of Betsy`s placement in the state institute, she was diagnosed as having Childhood Schizophrenia. That diagnosis assumed a continuity between the childhood disorder and adult psychosis.

However, there is considerable evidence from family and longitudinal studies that Autistic Disorder and the adult psychosis are not related; therefore, beginning with DSM-III, the childhood disorder has not been referred to as Schizophrenia.

Case work: Down Syndrome

A 15-year-old boy was brought to the emergency room by his mother, who, clutching the on-call resident's arm, pleaded, "You've got to admit him; I just can't take it anymore."

The patient had been taken home from a special school by his mother 6 months previously. The mother showed the resident papers from the school that indicated that the patient's IQ was 45.

He had had several placements, beginning at age 8. On visiting days, the boy always pleaded with his mother, "Mommy, take me home." After a year or so, the patient would be brought home by his mother, who had always been racked by guilt because of his retardation and her inability to manage him in the home.

The patient was an only child whose parents had been divorced for the past 4 years. The father had moved to another city.

During the last 6 months at home, the patient had increasingly become a behavior problem. He was about 5'9" tall and weighed close to 200 pounds.

He had become destructive of property at home--breaking dishes and a chair during angry tantrums--and, more recently, physically assaultive.

He had hit his mother on the arm and shoulder during a recent scuffle that began when she tried to get him to stop banging a broom on the apartment floor. The mother showed her bruises to the resident and threatened to call the nurse`s office if the hospital refused to admit her son.

On examination, the boy was observed to have the typical signs of Down's syndrome, including thick facial features, slightly protruding tongue, epicanthic fold of the eyelids, and Simian crease of the palms of the hands. With indistinct and slurred speech, the boy insisted that he "didn't mean to hurt anybody."

This boy's IQ of 45 indicates significantly subaverage general intellectual functioning. The need for placement in special schools since age 8 suggests that there have been severe concurrent deficits or impairments in adaptive behavior.
These two features, with onset before age 18, indicate the Axis II diagnosis of Mental Retardation. Because the IQ level is between 35 and 50, the severity level is Moderate.

The diagnosis of Mental Retardation should be made when the criteria are met, regardless of the presence of another diagnosis. In the presence of significant mental retardation, the issue of a Learning Disorder is dismissed, as the specific deficit would have to be out of proportion to the deficits in other areas of development.

A Pervasive Developmental Disorder can coexist with Mental Retardation; but unlike in this case, only when there is no interest or pleasure in social contact. Therefore, no diagnosis is warranted on Axis I.

This child, as is often the case, presents for admission because of destructive and aggressive behavior, not because of impairment in intellectual functioning.

This aggressive behavior is presumably a persistent pattern; nevertheless, the additional diagnosis of Conduct Disorder is not justified because there are none of the characteristic features of this disorder, such as stealing, lying, and running away from home.

In this case; Mental Retardation is apparently a result of Down's syndrome, which would be noted on Axis III.

The presence of any clinically relevant psychosocial and environmental problems is unclear from the available information. Therefore, one would not check any items from the Axis IV Psychosocial and Environmental Problems Checklist.

The patient`s highest level of functioning in the past year is very poor, owing to marked impairment in all areas of functioning; therefore, an appropriate highest global assessment of functioning (GAF) rating is only about 20. Because of the increase in dangerous behavior recently, necessitating the visit to the emergency room, the current GAF is rated 10.