INTRODUCTION

Cerebral palsy is defined as the non progressive neuromoter disorder of cerebral origin it include
heterogeneous clinical state of variable etiology and severity ranging from minor incapacitation
Most of the case is multiple neurological deficits and variable handicap. The term does not
include progressive ,degenerative and metabolic disorder of the nervous system.

Cerebral palsy (CP) is a group of permanent movement disorders that appear in early
childhood. Signs and symptoms vary between people. Often, symptoms include poor
coordination, stiff muscles, weak muscles, and tremors. There may be problems with sensation,
vision, hearing, swallowing and speaking.

It is difficulties to estimate the precise magnitude of the problem since mild case Are likely to be
missed. Approximately 1-2 per 100 live birth as a reasonable estimate of the incidence.

DEFINITION
Cerebral palsy (CP) is a non-progressive, non-contagious motor conditions that cause physical
disability in human development, chiefly in the various areas of body movement

Cerebral palsy is defined as "a group of permanent disorders of the development of movement
and posture, causing activity limitation, that are attributed to non-progressive disturbances that
occurred in the developing fetal or infant brain.

CAUSES
Cerebral palsy is due to damage occurring to the developing brain. This damage can occur during
pregnancy, delivery, the first month of life, or less commonly in early childhood

Micrograph showing a fetal (placental) vein thrombosis, in a case of fetal thrombotic

vasculopathy. This is associated with cerebral palsy and is suggestive of a hypercoagulable state
as the underlying cause.

 Preterm birth

Between 40% and 50% of all children who develop cerebral palsy were born prematurely In
those who are born with a weight between 1 kg and 1.5 kg CP occurs in 6%. Among those born
before 28 weeks of gestation it occurs in 11%.

 Term infants

In babies that are born at term risk factors include: problems with the placenta, birth defects, low
birthweight, breathing meconium into the lungs, a delivery requiring either the use of
instruments or an emergency Caesarean section, birth asphyxia, seizures just after birth,
respiratory distress syndrome, low blood sugar, and infections in the baby.
  Genetics

About 2% of all CP cases are inherited, with glutamate decarboxylase-1 being one of the
possible enzymes involved Most inherited cases are autosomal recessive, meaning both parents
must be carriers for the disorder in order to have a child with the disorder.

 Early childhood

After birth, other causes include toxins, severe jaundice, lead poisoning, physical brain injury,
stroke, shaken baby syndrome, incidents involving hypoxia to the brain (such as near drowning),
and encephalitis or meningitis. The three most common causes of asphyxia in the young child
are: choking on foreign objects such as toys and pieces of food, poisoning, and near drowning.

ETIOLOGY
Factor may operate parentally during delivery in the postnatal period .

 Cerebral malformation
 Perinatal hypoxia
 Birth trauma
 Chorioamnionitis
 Prothrobolic factor
 Acid base imbalance
 Indirect Hyperbilirubinemia
 Metabolic disturbance
 Intrauterine and acquired infection

PATHOPHYSIOLOGY
Prematurity

Hypoxia or ischemia infection /inflammatory

Increase extracellutar reactive oxygen or

proinflammatoryglutamate nitrogen species cytokinase

Excitotoxicity oxidative stress inflammation

  Intrinsic vulnerability of developing oligodendroglia
 Microglial activation
 Astrogliosis
 Neuronal /axonal damage

White mater gray matter

cortical
deep nuclear gray matter
cerebellum

Cerebral palsy

TYPES OF CEREBRAL PALSY

Cerebral Palsy is classified on basic of topographic distribution, neurologic finding and etiology.

1. Spastic cerebral palsy

This is the most commonest from (65%) and topographically classified in to spastic
quadriparesis, diplegia or hemiparesis .early diagnosis feature of neural damage include
abnormally persistent neonatal reflexes, feeding difficulty ,persistent cortical thump after 3
month age and firm grasp.

Spastic quadriparesisis more common in term babies and exhibit signs including
opisthotonicposture ,pseudo-bulber palsy, feeding difficulties ,restricted voluntary movement
and motor difficulties.

Spastic diplegiais commoner is preterm babies and associated with periventricular leukomalacia
.the lower limb are more severity affected with extension and adduction posture, brisk tendon
jerk and contracture .

Spastic hemiplesiais usually recognized after 4-6 months age. Early hand preference abnormal;
persistent fisting ,abnormal posture or gait disturbance may be the presenting complaint .vascular
insults, porencephaly or cerebral abnormities may be associated.
 2. Hypotonic (atonic) cerebral palsy

Despite pyramidal involvement these patient are atonic and hypotonic. Tendon reflexes are
normal or brisk Babinski response positive. They are often severely mentally retarded. In
cerebellar involvement, hypotonia is not associated with exaggerated reflexes. Muscle may show
fiber disproportion and delay CNS maturation is common.

3. Extrapyramidal cerebral palsy

This from accounts for 30% of cases the clinical manifestation include athetosis ,choreiform,
movement dystonia tremors and rigidity. Arm ,leg ,trunk ,may be involved.mental retarded and
hearing deficit may be present.high tone audiometry should performed.

4. Cerebellar involvement

This form is seen in less than 5% of the patients. There is hypotonia and hyporlefexia.ataxia and
intention tremors appearby the age of 2 years.

CLINICAL MANIFESTATIONS
 A person with cerebral palsy will generally show symptoms during the first three years
of life.
 The classical symptoms are spasticities, spasms, other involuntary movements (e.g.
facial gestures), unsteady gait, and problems with balance.
 All types of cerebral palsy are characterized by abnormal muscle tone, reflexes, or
motor development and coordination.
 Joint and bone deformities and contractures (permanently fixed tight muscles and
joints).
 Scissor walking (where the knees come in and cross) and toe walking (which can
contribute to a gait reminiscent of a marionette) are common.
 Secondary conditions can include seizures, epilepsy, apraxia, or other communication
disorders, eating problems, sensory impairments, mental retardation, learning
disabilities, urinary incontinence, fecal incontinence and/or behavioural disorders.

Language

 Speech and language disorders are common in people with cerebral palsy. The
incidence of dysarthria is estimated to range from 31% to 88%. [10] Speech problems are
associated with poor respiratory control, laryngeal and velopharyngeal dysfunction, and
oral articulation disorders that are due to restricted movement in the oral-facial muscles.
There are three major types of dysarthria in cerebral palsy: spastic, dyskinetic
(athetosis), and ataxic.Overalllanguage delay is associated with problems of intellectual
disability, hearing loss, and learned helplessness.
Pain and sleep

 Pain is common and may result from the inherent deficits associated with the condition,
along with the numerous procedures children typically face. Pain is associated with
tight or shortened muscles, abnormal posture, stiff joints, unsuitable orthosis, etc. There
is also a high likelihood of chronic sleep disorders secondary to both physical and
environmental factors.

Eating

Those with CP may have difficulty preparing food, holding utensils, or chewing and swallowing
due to sensory and motor impairments. An infant with CP may not be able to suck, swallow or
chew. Children with CP may have too little or too much sensitivity around and in the
mouth.]Fine finger dexterity, like that needed for picking up a utensil, is more frequently
impaired than gross manual dexterity, like that needed for spooning food onto a plate

DIAGNOSTIC EVALUATION
o History collection including mother’s gestational history.
o Examine the child, observing posture, movements, muscle tone, motor skills, and
checking the child's reflexes.
o Other conditions may have similar symptoms and need to be ruled out, such as
a tumor ormuscular dystrophy. The following tests will help the doctors carry out their
diagnosis:
o Blood tests
o Cranial ultrasound - an ultrasound scan can help doctors see an image of the child's brain
tissue
o MRI (magnetic resonance image) scan - this uses nuclear magnetic resonance of protons
to produce proton density images.
o CT scan help delineate the extent of cerebral damage in the case of cerebral palsy.

EVALUATION
 Eye: - nearly half of the patient have strabismus ,paralysis of gaze, cataract, coloboma,
retrolental, fibroplasia ,perceptual and refective errors.
 Ears: - partial and complete loss of hearing is usual in kernicterus. Brain damage due to
the rubella may be followed by receptive auditory aphasia.
 Speech: - aphasia, dysarthria and dyslalia are common among dyskinetic individual.
 Sensory defect: - astereogenosisand special disorientation are seen in one third if patient.
 Seizure: - spastic patient usually have generalized and focal tonic seizure. Seizure is
more common in disorders acquired postnatally .these patient response poorly
antiepileptic agents.
  Intelligence:- about a quarter of the children may have border line intelligence (IQ 80-
100) about half of them are severally mentally retarded.
 Miscellaneous:-inadequate thermoregulation and problem of social and emotional
adjustment are present in many cases. these children may have associated dental defects
and are more susceptible to infection.

TREATMENT
 Treatment for cerebral palsy is a lifelong multi-dimensional process focused on the
maintenance of associated conditions.
 Physiotherapy programs are designed to encourage the patient to build a strength base for
improved gait and movement, together with stretching programs to limit contractures.
 Occupational therapy helps adults and children maximize their function, adapt to their
limitations and live as independently as possible.
 Speech therapy helps control the muscles of the mouth and jaw, and helps improve
communication.
 Biofeedback is a therapy in which people learn how to control their affected muscles.
 Massage therapy is designed to help relax tense muscles, strengthen muscles, and keep
joints flexible.

DIFFERENTIAL DIAGNOSIS
 Neurodegenerative disorder :-Progressively increasing symptoms, familial pattern of
disease ,consanguinity, specific constellation of symptom and sign are usual clue for
neurometabolic disorder.
 Hydrocephalus and subdural effusion :_Head size is large , fontanel may bulge and
suture may separate .
 Brain tumor or space occupying lesion :-Lesion is progressive and feature or increase
ICP are evident .
 Muscle disorder :- Congenital myopathies and muscular dystrophy can mimic cerebral
palsy distribution of muscle weakness or others feature are characteristics hypotonia is
associated with diminished reflexes.
 Ataxia telangiectasia: -Ataxia may appear before the ocular telangiectasia are evident .

Prevention

Prevention of maternal infection, fetal or perinatal insult good maternal and neonatal care
reduces prevalence. Early diagnosis prompt adequate management plan care reduce the
residual neurological and psychosocial emotional handicap for the child and his family.

MANAGEMENT
  The management plan should be holistic ,involve the family and be directed to severity
type of neurological deficits and associated problem.
 Stress on improving posture, reducing tone, preventing contractures and early stimulation
is necessary .
 Identification of associated deficits is important for appropriate physiotherapy and
occupational therapy.
 Symptomatic treatment as prescribed for seizure.
 Tranquilizers are administered for behavior disturbance and muscle relaxant may be used
for improving muscle function.baclofen and tizanidine help to reduce spascity
 Diazepam may ameliorate spascity and athetosis.detroline sodium help in relaxant of
skeletal muscles.
 Dynamic contractures can be managed with botulinum toxin injection or alternatively
nerve block with phenol.
 Plastic orthoses may help to prevent contractures, surgical procedure for spasticity and
contractures may be required in selected patient.

THERAPEUTIC MANAGEMENT

Therapy for Cerebral Palsy »

 Acupuncture »
 Aqua Therapy »
 Behavioral Therapy »
 Chiropractic Intervention »
 Conductive Education »
 Hippotherapy »
 Intensive Suit Therapy »
 Massage Therapy »
 Music Therapy »
 Nutrition and Diet Plan Counseling »
 Occupational Therapy »
 Physical Therapy and Physiotherapy »
 Play Therapy »
 Recreation Therapy »
 Respiratory Therapy »
 Sensory Integration Therapy »
 Social Therapy »
 Speech and Language Therapy »
 Vocational Counseling »
  Acupuncture therapy

Acupuncture is a form of complementary medicine invented in China that is intended to treat

disease and relieve pain. The most common use of acupuncture is for pain relief from headaches,
back pain, joint pain and neck pain. For children and adults with Cerebral Palsy, acupuncture is a
relatively new therapy. Studies are being conducted for various symptoms experienced by those
with Cerebral Palsy, for example it is being studied for chronic pain relief, brain injury repair,
and hypertonicity.

 Aqua therapy

Aqua therapy is one of the best environments for a child with Cerebral Palsy to improve physical
functioning, especially if the child is not ambulatory. What sets aquatic therapy apart from
traditional physical therapy is that the water – which in and of itself is known for restorative and
detoxifying properties – provides buoyancy that makes aerobic and anaerobic exercises easy to
perform effectively, and safely. Additionally, if the water is warm, it has a massage effect on
muscles, joints and ligaments that often times are over-used and in pain.

Aquatic therapy aims to:

 Improve physical function

 Develop and maintaining physical control
 Improve psychological outlook
 Enhance self-concept and confidence
 Increase independence and quality of life

 Behavior therapy

Behavioral therapy has a positive influence not only on the quality of life for the child with
impairment, but also on those who support and care for the child. Behavioral therapy helps an
individual develop life skills, such as the ability to manage stressful situations or events that
result in anger or frustration, or that lead to negative outcomes, such as isolation, rejection, low
performance, attention deficit, or social-emotional deficiencies. Behavioral therapy can also be
helpful in addressing academic and social challenges often experienced in mental illness,
learning disabilities, and intellectually impaired individuals.

Other benefits to behavioral therapy include:

 Completing task
 Delaying gratification
 Developing friendships
 Excelling academically
 Finding acceptance
  Gaining perspective
 Managing emotions
 Maintaining focus
 Obtaining coping skills
 Overcoming emotional trauma
 Reducing anxiety
 Resisting temptation
 Resolving relationship conflicts
 Treating depression

 Hippo therapy

Hippotherapy is a form of physical, occupational and speech therapy that uses equine (horse)
movement to develop and enhance neurological and physical functioning by channeling the
movement of the horse. Hippotherapy is built on the concept that the individual’s neuromuscular
development is enhanced when their body makes adjustments to the gait, tempo, rhythm,
repetition and cadence of a horse’s movement.

Hippotherapy can help children with Cerebral Palsy on several fronts. Interacting with the animal
can lift a child’s spirits emotionally and psychologically while also providing valuable physical
exercise as the child learns how to ride the horse properly. A horse’s gait has three-dimensional
movement—equine movement–similar to a human that helps a child plan physical responses to
the horse’s movement. Horseback riding requires subtle adjustments and positioning to maintain
proper balance and posture.

Physical benefits include:

 Improved gross motor skills

 Trunk core strength
 Control of extremities
 Improved postural symmetry
 Reduced abnormal muscle tone
 Respiratory control

Cognitive benefits include:

 Improved attention
 Visual coordination
 Sensory input
 Tactile response
 Improved timing and grading of responses
 Improved ability to express thoughts, needs

Psychological benefits include:

  Enjoyable interactions with the animal
 Opportunities for social interaction
 Improved self-esteem

 Intensive suit therapy

Intensive suit therapy provides a child proper posture, muscle tone and patterns of movement
impaired by disability. It’s a complex intervention made of an orthotic suit that has strategically-
placed bungee cords adjusted in a manner to affect typical flexor and extensor muscle groups.

When paired with an extensive exercise regimen, wearing the suit helps eliminate pathological
reflexes many people with Cerebral Palsy contend with daily. According to research conducted
by manufacturers of therapeutic suits, performing the exercises as directed while wearing the suit
can reduce the effect of spasticity, athetosis, hypertonia, hypotonia, and ataxia. Additionally, suit
therapy has shown promise in treating children with sensory integration challenges.

 Play therapy

Play therapy incorporates the child’s physical abilities, cognitive functioning levels and
emotional needs in a safe, supportive environment. It is a therapeutic and psychological
intervention that uses play to help children with Cerebral Palsy develop a better sense of
inclusion using both directed and non-directed play.

Play therapy helps children with Cerebral Palsy express themselves. It sounds simple because the
capacity for play is hardwired in a child’s brain, but in actuality, learning to play can be
challenging for some children.

Play with purpose has also been a proven method for mental health professionals – and parents
and caregivers – to learn more about how a child interacts within their environment and what
their self-concept is. Therapy gives children a voice they might not be able to express in words,
and therefore, provides valuable insight into a child’s emotional state.

But play therapy’s benefits are more far more comprehensive, and include:

 Increased self-confidence
 Improved decision-making
 Improved feeling of control over their environment
 Enabled adaptive play
 Resolution of emotional barriers
 Reduced feelings of anxiety, depression and anger
 Developed cognitive problem-solving
 Increased autonomy
 Increased relaxation
  Increased learning
 Improved self-expression
 Decreased feelings of separateness

 Recreation therapy

Recreation therapy, also known as therapeutic recreation, focuses on designing ways in which an
individual can fully participate in recreational activities of their choice. Recreation therapists
work to identify the interest level, capabilities, adaptive approaches, and in some cases modified
processes required to successfully complete. Inclusion in life-enhancing activities improves a
child’s physical, mental and social experiences.

Recreation therapy has numerous benefits for children with Cerebral Palsy – it can improve
physical functionality, improve neurological connections associated with processing activities,
and provide opportunities for inclusion. Children involved with recreation therapy benefit within
both group and solitary environments. The time spent within activities of interest decreases
opportunities for depression, loneliness and frustration. In fact, recreation therapy provides a
greater sense of self-worth and accomplishment.

Physical benefits of recreation therapy include:

 Improved physical adeptness

 Increased strength and flexibility
 Improved physical fitness and health
 Improved athletic prowess
 Improved coordination

Psychological benefits of recreation therapy include:

 Acceptance of disability
 Increased social skills
 Increased ability to manage stress and depression
 Decreased anger and anxiety
 Diminished social isolation
 Improved body image
 Improved well-being and relaxation

Cognitive benefits of recreation therapy include:

 Improved behavior
 Increased analytical and decision-making skills
  Improved confidence
 Increased organization
 Increased perception

 Respiratory therapy

Although Cerebral Palsy does not cause respiratory distress, associative conditions can lead to
life-threatening respiratory issues, such as pneumonia, aspiration and choking. A child’s
respiratory health must be diligently monitored to treat symptoms and conditions before they
become unmanageable. Proper management of respiratory health can improve the quality of life.

it is estimated that 86% children with Cerebral Palsy have oral-motor dysfunction, which is an
inability to control the facial and neck muscles. This can lead to difficulty in swallowing,
breathing or communicating; it can also make a child more prone to choking, aspiration, and
pneumonia.

 Sensory integrative
Children born with Cerebral Palsy may display an abnormal degree of sensory processing,
whether decreased or increased. Sensory integrative dysfunction makes a child appear clumsy
when he or she walks. Often fine motor skills are affected. Sensory dysfunction can also cause
over-sensitivities or under-sensitivities that lead to mental and physical distraction or fatigue.
Problems with sight, hearing, and balance are also addressed.

Who benefits from sensory integration therapy?

Children are the largest benefactors of sensory integration therapy, but parents and caregivers
also benefit.

By providing coping strategies and treating the condition, therapists help children overcome
these issues that, at least initially, may seem insurmountable. Success is achieved by
implementing treatment that will help children build the mental and physical framework within
their nervous system to properly perceive sensory input, regulate their responses, and understand
the significance behind a particular, texture, movement, or sound.

All of these skills must be mastered for a child to maximally benefit from other therapies.

Benefits to sensory integration therapy include:

 Lessen sensory defensiveness

 Develop positive behavior patterns
  Correctly interpret sensory input
 Minimize input intolerance
 Eliminate fear
 Reduce negative physical reactions
 Create physical equilibrium and sense of space
 Encourage play and socialization
 Anticipate action and outcome

 Social therapy

Children with impairment may experience any number of social challenges, such as social
anxiety, relationship problems, depression or attention deficit. Anxiety, panic, shyness, or
emotional pain can be replaced with emotional growth through learning new ways of perceiving,
thinking and interacting. The effect of social therapy can be empowering. Often, pain is
recognized and released. The child develops new ways to respond to people, situations and
moments.

Common social issues those with Cerebral Palsy experience include:

 Anxiety
 Shyness
 Emotional connectivity
 Frustration
 Sadness
 Depression
 Confidence
 Self-consciousness

The goals of social therapy are:

 Teaching children to learn through experiences with other people

 Encouraging positive social interactions and cooperation
 Helping children develop confidence
 Creating sustainable social environments for children
 Empowering a child to contribute to the group
 Eliminating physical and psychological barriers to social interaction
 Realizing the benefits and joy of interaction

Sometimes, children with Cerebral Palsy often experience physical and psychological symptoms
of social phobia, or an extreme, debilitating fear of social interaction that can cause a withdrawal
from everyday life. Others are more isolated and protected from experiencing social settings.
Social therapy can help improve and alleviate:

 Trembling
 Nausea
  Increased heart beat
 Fear and anxiety
 Embarassment
 Abnormal sleep

Vocational counseling

Vocational counseling assesses an individual’s intelligence, aptitude, interests, abilities and skill
levels in order to create and follow a career path. Vocational therapists partner with businesses,
government agencies, educational institutions and the employment industry to develop mutually
beneficial opportunities for individuals with special needs. They also assist in assessing, training
and developing individuals for positions and advancement.

What are the benefits of vocational counseling?

To those touched by Cerebral Palsy, employment or vocation might initially seem like a remote
possibility, but the good news is many achieve gainful employment and successful careers.

Individuals with Cerebral Palsy, depending on their abilities and severity of their condition, work
in full- or part-time positions, attend specialized training, and also attend college.

Vocational counseling makes this possibility a reality by pinpointing capabilities, not limitations.
Most want to work and achieve independence; vocational counseling provides a pathway to
achieve and master a vocation that is appropriate for their skill level and provides a starting point
for the individual to develop new skill sets.

For those with Cerebral Palsy, the benefits of vocational counseling are:

 Access to job training programs

 Opportunities to network
 Access to a job coaches
 Job placement assistance
 Economic autonomy and independence
 Self-esteem and self-worth
 Social interaction
 Professional coaching

 Music therapy

Music – with all of its complex beauty – not only relaxes children, it also soothes them during
times of stress. Many of us may think it’s simply the enjoyment of listening to music that relaxes
us, but in actuality, there’s something physical that occurs. Music therapy has some unexpected
and valuable benefits for individuals with Cerebral Palsy.

 Chiropractic therapy
Chiropractic care, a form of complementary or alternative, or CAM, health practice, is
technically considered a manipulative and body-based therapeutic method. Chiropractic care is a
hands-on approach to therapy that often centers around the adjustment to the spine and joints in a
way that influences the body’s nervous system and natural defense mechanisms for the purpose
of alleviating pain and improving health and well-being.

Chiropractic interventions are used to improve forms of musculoskeletal pain, including lower-
back, neck, shoulder, headaches, hand and foot problems, as well as for specific health
conditions such as Cerebral Palsy, fibromyalgia and attention deficit hyperactivity disorder.

 Physiotherapy
Physiotherapy programs are designed to encourage the patient to build a strength base for
improved gait and volitional movement, together with stretching programs to limit contractures.
Many expert.believe that lifelong physiotherapy is crucial to maintain muscle tone, bone
structure, and prevent dislocation of the joints

 Speech therapy
Speech therapy helps control the muscles of the mouth and jaw, and helps improve
communication. Just as CP can affect the way a person moves their arms and legs, it can also
affect the way they move their mouth, face and head.

 Conductive therapy
Conductive education (CE) was developed in Hungary from 1945 based on the work of
AndrásPető. It is a unified system of rehabilitation for people with neurological disorders
including cerebral palsy, Parkinson's disease and multiple sclerosis, amongst other conditions. It
is theorised to improve mobility, self-esteem, stamina and independence as well as daily living
skills and social skills

 Biofeedback
Biofeedback is a therapy in which people learn how to control their affected muscles.
Biofeedback therapy has been found to significantly improve gait in children with cerebral palsy.

 Massage therapy
Massage therapy is designed to help relax tense muscles, strengthen muscles, and keep joints
flexible. More research is needed to determine the health benefits of these therapies for people
with CP.

 Occupational therapy
Occupational therapy helps adults and children maximize their function, adapt to their limitations
and live as independently as possible. A family-centred philosophy is used with children who
have CP. Occupational therapists work closely with families in order to address their concerns
and priorities for their child.

 Nutritional diet therapy

With the majority of individuals with Cerebral Palsy reporting feeding or digestive difficulties, a
dietary counseling program can be highly beneficial. Skilled practitioners work with primary
care physicians to adjust diet, intake, substance, and supplements in ways that contribute
significantly to an individual’s overall health. Learn what to feed, how to prepare food, how to
feed and when to feed.

Those with Cerebral Palsy who may benefit from nutrition and dietary therapy include
individuals with:

 Abdominal pain
 Aspiration
 Bladder control
 Bowel (intestinal) obstruction
 Bowel incontinence
 Chewing difficulties
 Choking
 Chronic pulmonary aspiration
 Constipation
 Delayed gastric emptying
 Delayed growth and development
 Dental caries/tooth decay
 Diarrhea
 Drooling
 Enuresis (bed wetting)
 Esophageal bleeding
 Esophagitis
 Failure to thrive
 Feeding difficulties
 Flatulence
 Gastroesophageal disease
 Gastroesophageal reflux (GERD)
 Gastrointestinal motility
 Gastrointestinal tract bleeding
 Genitourinary problems
 Growth impairment (maturation)
 Halitosis
 Immobilization
 Inadequate oral intake
 Incontinence
 Intestinal dysmotility
 Irritable bowel syndrome
 Malnutrition
 Obesity and weight management
 Oral motor dysfunction
 Pneumonia
 Primary intestinal pseudo obstruction
 Prolonged colonic transit
 Pseudobulbar palsy
 Sucking difficulties
 Swallowing difficulties
 Undernourishment
 Urinary incontinence
 Urinary tract infections
 Vitamin deficiency
 Vomiting
 MENTAL RETARDATION
INTRODUCTION

Mental Retardation (MR) is not a disease but a condition in which the intellectual faculties are
never manifested or have never been developed sufficiently to enable the retarded person to
acquire such an amount of knowledge as persons of his own age and placed in similar
circumstances with himself are capable of receiving.

DEFINITIONS

Mental retardation refers to significantly sub-average general intellectual fuctioning, resulting in

or associated with current impairments in adaptive behavior and manifested during the
developmental period. American Association On Mental Deficiency,1983

Mental retardation as:

1) Significantly sub-average intellectual functioning-ie an IQ of approximately 70 or below.

2) Deficits or impairments in adaptive functioning.
3) Onset before age of 18 years.

DSM IV

Mental retardation is a condition of arrested or incomplete development of the mind, which is

especially characterized by impairment of skills manifested during development period that
contribute to cognitive language, motor and social abilities

ICD-10

INCIDENCE

Individuals with MR represent 1% to 3% of the general population. MR is approximately

1.5 times more common in boys than girls.
ETIOLOGY

GENETIC FACTORS
 Down’s syndrome
 Fragile X syndrome
 Trisomy X syndrome
 Turner’s syndrome
 Cat-cry syndrome
 Prader-Willi syndrome

METABOLIC DISORDERS

 Phenylketonuria (PKU)
 Wilson’s disease
 Galactosemia

CRANIAL MALFORMATION

 Hydrocephaly
 Microcephaly

GROSS DISEASE OF BRAIN

 Tuberous sclerosis
 Neurofibromatosis
 Epilepsy

PRE NATAL FACTORS

INFECTIONS
 Rubella
 Cytomegalovirus
 Syphillis
 Toxoplasmosis, herpes simplex.

ENDROCRINE DISORDER
 Hypothyroidism
 Hypoparathyroidism
 Diabetes mellitus

PHYSICAL DAMAGE AND DISORDERS

 Injury
 Hypoxia
 Radiation
 Hypertension
 Anaemia
  Emphysema

 INTOXICATION
 Lead
 Certain drugs
 Substance abuse

 PLACENTAL DYSFUNCTION
 Toxemia of pregnancy
 Placenta PREVIA
 Cord prolapse
 Nutritonal growth retardation

 PERINATAL FACTORS
 Birth asphyxia
 Prolonged or difficult birth
 Prematurity

 POSTNATAL FACTORS
1. INFECTIONS

 Encephalitis
 Measles
 Meningitis

 ENVIRONMENTAL AND SOCIO-CULTURAL FACTORS

 Cultural deprivation
 Low socio-economic status
 Child abuse

CLASSIFICATION

 Mild (Educable)
 Moderate (Trainable)
 Severe (Dependent retarded)
 Profound (Life support)
MILD

1. Ability to perform self-care activities: Capable of independent living, with

assistance during time of stress.
2. Cognitive/Educational capabilities: Capable of academic skills to sixth grade. As
adult can achieve vocational skills for minimum self-support.
3. Social/Communication capabilities: Capable of developing social skills. Functions
in a structured sheltered setting.
4. Psychomotor capabilities: Psychomotor skills usually not affected although
may have some slight problems with coordination.
MODERATE

1. Ability to perform self care-activities: Can perform some activities

independently, requires supervision.
2. Cognitive/Educational capabilities: Capable of academic skill to second
grade level. As adult may be able to contribute to own support in sheltered
workshop.
3. Social/Communication capabilities: May experience some limitation in
speech communication. Difficulty adhering to social convention may
interfere with peer relationships.
4. Psychomotor capabilities: Motor development is fair.Vocational
capabilities may be limited to unskilled gross motor activities
SEVERE

1. Ability to perform self-care activities: May trained in elementary hygiene skills,

requires complete supervision.
2. Cognitive/Educational activities: Unable to benefit from academic or vocational
training. Profits from systematic habit training.
3. Social/communication capabilities: Minimal verbal skills. Wants and needs often
communicate by acting-out behavior.
4. Psychomotor capabilities: Poor psychomotor development. Only able to perform
simple tasks under close supervision.

PROFOUND

1. Ability to perform activities: No capacity for independent functioning, requires

constant aid and supervision.
2. Cognitive/Educational capabilities: Unable to profit from academic or vocational
training. May respond to minimal training in self-help if presented in the close
context of a one-to-one relationship.
3. Capacity for socialization skills.
4. Psychomotor capabilities: Lack of ability for both fine and gross motor
movements, requires constant supervision and care. May be associated with other
physical disorders.

(Adopted from American Psychiatric Association,2000 and Sadock and Sadock 2003)

DIAGNOSTIC PROCEDURES

 History collection from parents and care takers.

 Physical examination
 Neurological examination
 Assessing milestones development.
 Investigations
a) Urine and blood examination for metabolic disorders.
b) Culture for cytogenic and biochemical studies.
 c) Amniocentesis in infant for chromosomal disorders.
d) Chronic villi sampling.
 Hearing and speech evaluation.
 EEG, especially if seizures are present.
 CT scan or MRI brain eg:TB
 TFT when cretinism is suspected.
 Psychological test

PROGNOSIS

The prognosis for children with MR has improved and institutional care is no longer
recommended. These children are mainstreamed whenever feasible and are taught
survival skills.

DISORDERS FREQUENT AMONG MR

I PHYSICAL DISORDERS

 Sensory disorders: Defects in hearing and vision.

 Motor disorders: spasticity, ataxia, epilepsy etc.

II PSYCHIATRIC DISORDERS

a) Schizophrenia: Characterized by poverty of thinking, less elaborate

delusions, simple and repetitive hallucinations. Treatment is same as of
patient with normal intelligence. Diagnosed only if there is deterioration in
intellectual or social functioning. Difficult to diagnose if IQ below 45
b) Mood disorders:
o Depressive disorders: Diagnosed on appearance of sadness,
retardation or agitation, suicide attempts may be seen.
o Mania: Diagnosed mainly in over activity and behavioral signs
suggestive of elevation of mood.
c) Neurosis: Common in less severely retarded especially while
facing changes in the routine of their lives. Clinical pictures are often missed.
Treated by increased adjustment to environment.

d) Personality disorders: Common in mentally retarded.

e) Organic psychiatric disorders: Dementia is usually diagnosed after 18
years or when there is definite decline in intellectual capacity and adaptive
behaviors.
f) Behavior disorders: Mannerisms, head banging and rocking are common
among severely retarded (seen in about 40% f children and 20% of
adults.).Repeated self injurious behavior, hyperkinetic syndrome, temper-
tantrums, self-stimulation are also evident.
 g) Sexual problems: Masturbation in public is the most frequent problem.
.Severely mentally retarded is not likely to become good parents.

EFFECTS OF MENTAL RETARDATION ON THE FAMLY

 Distress, feelings of rejection

 Depression,guilt,shame or anger
 Rejection of child.
 Social problems.
 Overindulgence.
 Marital disharmony.(in some)
 Burden of care for their child.
 Dissatisfaction about medical and social services9even when they are normal)

PREDISPOSING FACTORS

Important predisposing factors are low socio-economic strata, low birth weight
(of child.), advanced maternal age and consanguinity.

DIFFERENTIAL DIAGNOSIS

1. Delayed maturation(specific developmental disorders)

2. Blindness or other sensory defects.
3. Childhood psychoses(childhood onset schizophrenia)
4. Childhood autism
5. Severe neurosis
6. Systematic disorders with physical handicap.
7. Deprived children wit insufficient stimulation
8. Epilepsy
9. States due to the side effects of drugs (antipsychotics,anticonvulsants)

MANAGEMENT

No satisfactory treatment is available till today. No drugs are available to increase the level of
intelligence. Most of the mentally retarded children brought for treatment can only be benefited
only to a limited extent.

PRIMARY PREVENTION

1) Health promotion: It is directed at

 Good antenatal care and encouraging deliveries in hospitals under proper

supervision and care.
 Improving the socio-economic status of the country.
  Education of the public to help in early detection of MR also, to remove
various misconceptions about its causes and treatment.
 Facilitating research to identify the causes, and to invent new methods of
treatment.
2) Specific protection

 Good prenatal, natal and postnatal care to the pregnant mother at risk.
 Genetic counseling to at risk patients eg:in phenylketonuria.
 Avoid childbirths in late age of mother(e.g.: to prevent Down’s syndrome)
 Avoid consanguinal marriages in case the hereditary factors are operative.
 Avoid marriage of mentally retarded (especially to mentally retarded) where
strong factors are operating.(e.g.: TB)
 Vaccination of girls with rubella vaccine to prevent teratogenecity in fetus due
to rubella.
 Avoid giving pertusis vaccine to children with history of convulsions or
neurological abnormalities.

SECONDARY PREVENTION

 Early detection and treatment of preventable disorders can be effectively treated at an

early stage by dietary control or hormone replacement therapy.
 Early recognition of presence of MR.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 handicap. Rehabilitation is aimed at reducing disability and providing optimal functioning in a
child with MR

COUNSELLING TO PARENTS

Parents should be explained about the causation and prognosis of MR

 To educate parents and families in caring for the mentally handicapped(eg:

training house hold activities)
 Special supervision for the physically handicapped or those severely and
profoundly mentally retarded.
 Treatment of psychological problems in parents(eg:depression in mother resulting
in under stimulation of a child resulting in retardation)

HOSPITILIZATION
 It is estimated that about 4/1000 children are severely mentally retarded and about one
fourth to one third needs hospitalization.

Indications

a) Behavioral difficulties due to

 Attention deficit disorder with hyper kinesis
 Destructive,assaultive behavior
 Psychoses
 Organic psychosis
b) Social factors
 Overcrowding
 Incompetent parents
 Mentally retarded or psychotic parent
 Single parenthood
 No one to look after

CONCLUSION

Mental retardation is not disease but a condition in which the intellectual faculties are
never manifested or never been developed sufficiently to enable the retarded person to acquire
such an amount of knowledge as persons of his own age and placed in similar circumstances
with himself are capable of receiving.