Mental retardation (MR) is a developmental disability that first appears in children under the age of 18. It is defined 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 begins in childhood or adolescence before the age of 18. In most cases, it persists throughout adult life. A diagnosis of mental retardation is made if an individual has an intellectual functioning level well below average, as well as significant limitations in two or more adaptive skill areas. Intellectual functioning level is defined by standardized tests that measure the ability to reason in terms of mental age (intelligence quotient or IQ). Mental retardation is defined as an IQ score below 70–75. Adaptive skills is a term that refers to skills needed for daily life. Such skills include the ability to produce and understand language (communication); home-living skills; use of community resources; health, safety, leisure, self-care, and social skills; self-direction; functional academic skills (reading, writing, and arithmetic); and job-related skills.
In general, mentally retarded children reach such developmental milestones as walking and talking much later than children in the general population. Symptoms of mental retardation may appear at birth or later in childhood. The child's age at onset depends on the suspected cause of the disability. Some cases of mild mental retardation are not diagnosed before the child enters preschool or kindergarten. These children typically have difficulties with social, communication, and functional academic skills. Children who have a neurological disorder or illness such as encephalitis or meningitis may suddenly show signs of cognitive impairment and adaptive difficulties.
Mental retardation varies in severity. The Diagnostic and Statistical Manual of Mental Disorders , fourth edition, text revision ( DSM-IV-TR ), which is the diagnostic standard for mental health care professionals in the United States, classifies four different degrees of mental retardation: mild, moderate, severe , and profound . These categories are based on the person's level of functioning.
Mild mental retardation
Approximately 85% of the mentally retarded population is in the mildly retarded category. Their IQ score ranges from 50–70, and they can often acquire academic skills up to about the sixth-grade level. They can become fairly self-sufficient and in some cases live independently, with community and social support.
Moderate mental retardation
About 10% of the mentally retarded population is considered moderately retarded. Moderately retarded persons have IQ scores ranging from 35–55. They can carry out work and self-care tasks with moderate supervision. They typically acquire communication skills in childhood and are able to live and function successfully within the community in such supervised environments as group homes .
Severe mental retardation
About 3–4% of the mentally retarded population is severely retarded. Severely retarded persons have IQ scores of 20–40. They may master very basic self-care skills and some communication skills. Many severely retarded individuals are able to live in a group home.
Profound mental retardation
Only 1–2% of the mentally retarded population is classified as profoundly retarded. Profoundly retarded individuals have IQ scores under 20–25. They may be able to develop basic self-care and communication skills with appropriate support and training. Their retardation is often caused by an accompanying neurological disorder. Profoundly retarded people need a high level of structure and supervision.
The American Association on Mental Retardation (AAMR) has developed another widely accepted diagnostic classification system for mental retardation. The AAMR classification system focuses on the capabilities of the retarded individual rather than on his or her limitations. The categories describe the level of support required. They are: intermittent support; limited support; extensive support , and pervasive support . To some extent, the AAMR classification mirrors the DSM-IV-TR classification. Intermittent support, for example, is support that is needed only occasionally, perhaps during times of stress or crisis for the retarded person. It is the type of support typically required for most mildly retarded people. At the other end of the spectrum, pervasive support, or life-long, daily support for most adaptive areas, would be required for profoundly retarded persons. The AAMR classification system refers to the "below-average intellectual function" as an IQ of 70–75 or below.
The prevalence of mental retardation in North America is a subject of heated debate. It is thought to be between 1%–3% depending upon the population, methods of assessment, and criteria of assessment that are used. Many people believe that the actual prevalence is probably closer to 1%, and that the 3% figure is based on misleading mortality rates; cases that are diagnosed in early infancy; and the instability of the diagnosis across the age span. If the 1% figure is accepted, however, it means that 2.5 million mentally retarded people reside in the United States. The three most common causes of mental retardation, accounting for about 30% of cases, are Down syndrome, fragile X, and fetal alcohol syndrome. Males are more likely than females to have MR in a 1.5:1 ratio.
Causes and symptoms
Low IQ scores and limitations in adaptive skills are the hallmarks of mental retardation. Aggression, self-injury, and mood disorders are sometimes associated with the disability. The severity of the symptoms and the age at which they first appear depend on the cause. Children who are mentally retarded reach developmental milestones significantly later than expected, if at all. If retardation is caused by chromosomal or other genetic disorders, it is often apparent from infancy. If retardation is caused by childhood illnesses or injuries, learning and adaptive skills that were once easy may suddenly become difficult or impossible to master.
In about 40% of cases, the cause of mental retardation cannot be found. Biological and environmental factors that can cause mental retardation include:
About 30% of cases of mental retardation is caused by hereditary factors. Mental retardation may be caused by an inherited genetic abnormality, such as fragile X syndrome. Fragile X, a defect in the chromosome that determines sex, is the most common inherited cause of mental retardation. Single-gene defects such as phenylketonuria (PKU) and other inborn errors of metabolism may also cause mental retardation if they are not discovered and treated early. An accident or mutation in genetic development may also cause retardation. Examples of such accidents are development of an extra
Prenatal illnesses and issues
Fetal alcohol syndrome (FAS) affects one in 3,000 children in Western countries. It is caused by the mother's heavy drinking during the first twelve weeks (trimester) of pregnancy. Some studies have shown that even moderate alcohol use during pregnancy may cause learning disabilities in children. Drug abuse and cigarette smoking during pregnancy have also been linked to mental retardation.
Maternal infections and such illnesses as glandular disorders, rubella, toxoplasmosis, and cytomegalovirus (CMV) infection may cause mental retardation. When the mother has high blood pressure (hypertension) or blood poisoning (toxemia), the flow of oxygen to the fetus may be reduced, causing brain damage and mental retardation.
Birth defects that cause physical deformities of the head, brain, and central nervous system frequently cause mental retardation. Neural tube defect, for example, is a birth defect in which the neural tube that forms the spinal cord does not close completely. This defect may cause children to develop an accumulation of cerebrospinal fluid inside the skull (hydrocephalus). Hydrocephalus can cause learning impairment by putting pressure on the brain.
Childhood illnesses and injuries
Hyperthyroidism, whooping cough, chickenpox, measles, and Hib disease (a bacterial infection) may cause mental retardation if they are not treated adequately. An infection of the membrane covering the brain (meningitis) or an inflammation of the brain itself (encephalitis) can cause swelling that in turn may cause brain damage and mental retardation. Traumatic brain injury caused by a blow to the head or by violent shaking of the upper body may also cause brain damage and mental retardation in children.
Ignored or neglected infants who are not provided with the mental and physical stimulation required for normal development may suffer irreversible learning impairment. Children who live in poverty and suffer from malnutrition, unhealthy living conditions, abuse, and improper or inadequate medical care are at a higher risk. Exposure to lead or mercury can also cause mental retardation. Many children have developed lead poisoning from eating the flaking lead-based paint often found in older buildings.
If mental retardation is suspected, a comprehensive physical examination and medical history should be done immediately to discover any organic cause of symptoms. Such conditions as hyperthyroidism and PKU are treatable. If these conditions are discovered early, the progression of retardation can be stopped and, in some cases, partially reversed. If a neurological cause such as brain injury is suspected, the child may be referred to a neurologist or neuropsychologist for testing.
A complete medical, family, social, and educational history is compiled from existing medical and school records (if applicable) and from interviews with parents. Children are given intelligence tests to measure their learning abilities and intellectual functioning. Such tests include the Stanford-Binet Intelligence Scale , the Wechsler Intelligence Scales, the Wechsler Preschool and Primary Scale of Intelligence, and the Kaufman Assessment Battery for Children . For infants, the Bayley Scales of Infant Development may be used to assess motor, language, and problem-solving skills. Interviews with parents or other caregivers are used to assess the child's daily living, muscle control, communication, and social skills. The Woodcock-Johnson Scales of Independent Behavior and the Vineland Adaptive Behavior Scale (VABS) are frequently used to evaluate these skills.
Federal legislation entitles mentally retarded children to free testing and appropriate, individualized education and skills training within the school system from ages three to 21. For children under the age of three, many states have established early intervention programs that assess children, make recommendations, and begin treatment programs. Many day schools are available to help train retarded children in such basic skills as bathing and feeding themselves. Extracurricular activities and social programs are also important in helping retarded children and adolescents gain self-esteem.
Training in independent living and job skills is often begun in early adulthood. The level of training depends on the degree of retardation. Mildly retarded people can often acquire the skills needed to live independently and hold an outside job. Moderate to profoundly retarded persons usually require supervised community living in a group home or other residential setting.
Family therapy can help relatives of the mentally retarded develop coping skills. It can also help parents deal with feelings of guilt or anger. A supportive, warm home environment is essential to help the mentally retarded reach their full potential.
People with mild to moderate mental retardation are frequently able to achieve some self-sufficiency and to lead happy and fulfilling lives. To reach these goals, they need appropriate and consistent educational, community, social, family, and vocational supports. The outlook is less promising for those with severe to profound retardation. Studies have shown that these persons have a shortened life expectancy. The diseases that are usually associated with severe retardation may cause the shorter life span. People with Down syndrome will develop the brain changes that characterize Alzheimer's disease in later life and may develop the clinical symptoms of this disease as well.
Immunization against diseases such as measles and Hib prevents many of the illnesses that can cause mental retardation. In addition, all children should undergo routine developmental screening as part of their pediatric care. Screening is particularly critical for those children who may be neglected or undernourished or may live in disease-producing conditions. Newborn screening and immediate treatment for PKU and hyperthyroidism can usually catch these disorders early enough to prevent retardation.
Good prenatal care can also help prevent retardation. Pregnant women should be educated about the risks of alcohol consumption and the need to maintain good nutrition during pregnancy. Such tests as amniocentesis and ultrasonography can determine whether a fetus is developing normally in the womb.
American Psychiatric Association. "Mental Retardation." In Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text revision. Washington, DC: American Psychiatric Press, Inc., 2000.
Jaffe, Jerome H., M.D. "Mental Retardation." In Comprehensive Textbook of Psychiatry, edited by Benjamin J. Sadock, M.D. and Virginia A. Sadock, M.D. 7th edition. Philadelphia, PA: Lippincott Williams and Wilkins, 2000.
Julian, John N. "Mental Retardation." In Psychiatry Update and Board Preparation, edited by Thomas A. Stern,M.D., and John B. Herman, M.D. New York: McGraw Hill, 2000.
Bozikas,Vasilis, M.D., and others. "Gabapentin for Behavioral Dyscontrol with Mental Retardation." American Journal Psychiatry June 2001: 965-966.
Margolese, Howard C., M.D., and others. "Olanzapine-Induced Neuroleptic Malignant Syndrome with Mental Retardation." American Journal Psychiatry July 1999: 1115A-1116.
American Association on Mental Retardation (AAMR) [The organization voted to change its name to American Association on Intellectual Disabilities on March 25,2002.]. 444 North Capitol Street, NW, Washington, D.C.20001. (800) 424-3688. <http://www.aamr.org> .
The Arc of the United States (formerly Association of Retarded Citizens of the United States). 1010 Wayne Avenue, Silver Spring, M.D. 20910. (301) 565-3842. <http://thearc.org> .
National Information Center for Children and Youth and Disabilities. P.O. Box 1492,Washington, D.C. 20013.(800) 695-0285. <http://www.nichcy.org> .
Paula Anne Ford-Martin, M.A.