Mental Retardation & IQ Elham Shirazi M.D. Board of General Psychiatry Board of Child & Adolescent Psychiatry
Conceptualization of IQ vary by ethnic group
Lay person understand IQ as: Practical problem solving Verbal ability Social competence
Latino: Understand IQ as social competence skills
Asian: Understand IQ as cognitive competence
Teachers : Understand IQ as cognitive competence
Taiwan: Cognitive ability Interpersonal & intrapersonal competence Intellectual self-assertion: Knowing when to show one’s IQ Intellectual self-effacement: Knowing when not to show one’s IQ
In the past: Measuring cognition & intelligence have been viewed as synonymous Contemporary developmentalists: Attempt to redefine the concept of intelligence in transactional terms to include environmental factors,& emotional & social maturation!
IQ can be defined as: Ability to assimilate factual knowledge Recall recent & remote events Reason logically Manipulate concepts (number & words) Translate abstract to literal
Translate literal to abstract Analyze & synthesize forms Deal meaningfully & accurately with problems Deal meaningfully & accurately with priorities
Triarchic Theory of Intelligence Intelligence is composed of: Analytic abilities Creative abilities Practical abilities These abilities are relatively uncorrelated
Analytic Ability Analytic thinking: Analyzing Comparing Evaluating To solve familiar problems by: Manipulating the elements of the problem Manipulating the relationships among elements
Creative Ability Creative thinking: Creating Inventing Designing
To solve new kinds of problems: Require thinking about the problem & its elements in a new way
Practical Ability Practical thinking: Applying Using Doing To solve problems by applying what we know to everyday contexts
Predict job performance more than IQ
Gardner: Linguistic Mathematical Spatial Musical Kinesthetic Naturalistic Interpersonal intrapersonal
Emotional IQ Self awareness Emotional management Impulse control Empathy Motivation
Social IQ Intention Deception Theory of mind Impulse control Social competition
Conventional tests measure only analytical abilities (not creative & practical abilities) What tests measure is only a part of IQ! People’s intuitive concept of IQ is much broader than what is presented by tests
No evidence that early education will raise a child’s IQ on permanent basis High-quality age-appropriate programs have long-term positive benefits for disadvantaged children
Young children need to learn: Basics of the world: (sights, colors, shapes, textures, tastes, up & down, behind & on top of, what floats & what sinks, forms, smells, animals, plants,…) from their exploration & discoveries (not formal instructions) Not academic subjects!
Diagnostic Approach for All Ages 1. Family History: Mental retardation, congenital anomalies, later-onset disability
2. Gestational History: Maternal infection, fever, drugs, fetal growth delay, distress
3. Birth History: Distress, meconium aspiration, asphyxia 4. Childhood History: Trauma, pica, asphyxia, loss of acquired developmental milestones
5. Physical examination: A. If dysmorphic features present: Do detailed evaluations: Chromosomal analysis, Metabolic evaluation, other testing
B. If no congenital anomalies: Do metabolic screening: Amino acids, Organic Acids, Lactate, Pyruvate, Thyroid Function, Lead, Revised newborn screen (Triglyceride, Carnitine, Urine Mucopolysaccharides)
6. Confirm diagnosis
Role of Psychiatrist in MR Field Provision of clinical services Prevention of mental disorders (early diagnosis, emotional support to child & family) Psycho-education for family Treatment of behavioral problems
Participation in an interdisciplinary developmental team Not making only a “medication review”, but a “patient review” Focus on all aspects of diagnosis & treatment
Antidepressants First line agent for: Depression Obsessive Compulsive Symptoms Anxiety Disorders
TCA Lowering seizure threshold General population: 1/1000 MR: 1/5 May require lower doses than normal!
A subgroup of PDD: Exhibits extraordinary sensitivity to drugs (disinhibition, increased target symptoms,…) Start low & go slow!
A subgroup of SIB patients: Exhibits self-restraining behaviors (binding their extremities, wear helmets for self protection,…) The possibility of SIB as a compulsion! SSRIs may be useful
Anticonvulsants Epilepsy Cyclical mood disorders Impulsive aggression Behavioral problems
MR is often comorbid with seizures If there is a behavioral problem, Anticonvulsants may be helpful for both!
Cabamazepine Na Valproate Gabapentine Lamotrigine Topiramate Phenobarbital
Improvement of communication Cooperation Restlessness Challenging behavior
Topiramate: Decreasing skin-picking behavior in Prader-Willi syndrome Phenobarbital withdrawal: Decrease SIB & aggression! (In patients with brain damage, epilepsy, & MR, Phenobarbital may result in hyperactivity & behavioral problems)
Anxiolytics Confusion Cognitive impairment Memory impairment Unsteadiness Paradoxical excitement Behavioral disinhibition Increase in stereotypic behaviors Increase in SIB
Alprazolam Clonazepam Lorazepam Widely used for acute anxiety (particularly associated with procedures) Consider absence of previous abnormal responses!
Buspiron No matter or cognitive toxicity
Neuroleptics Most widely prescribed class for any behavioral symptoms in MR Risk of cognitive toxicity, EPS, & tardive dyskinesia is greater in MR Spontaneous abnormal involuntary movements are common in MR A confounding factor in evaluating rate of EPS in MR
Risperidone 0.02-0.06 mg/kg Severe disruptive behavior Psychosis Aggression SIB Most common side effects:
Sedation, weight gain
Clozapine Olanzapine Sulpride Were effective Thioridazine 15-300 mg/day Concern: Increase QT interval
Psychstimulants Good for MR + ADHD Higher than expected rates of motor tics & emotional lability
Lithium Aggressive behaviors in MR Cyclic mood disorders + MR Cognitive dulling Appropriate fluid intake is important
Beta-antagonists Up to 1000 mg/day Rage episodes after brain damage Low frustration tolerance in MR Generic aggression in MR
Monitor BP & PR Depression may be a side effect !
Opioid-Antagonists Naltrexone 0.5 – 2 mg/kg Up to 200 mg/day in adults Well tolerated in MR SIB: effective in 50% of recipients Most likely side effect: Sedation Keep in mind the long T ½: 72 h in brain
Melatonin 3 mg 1-2 h before HS Increase sleep efficiency Sleep problems are often significant in some MR persons
Nootropics Piracetam Placebo-controlled crossover trial in Down Syndrome: 80-100 mg/day No consistent benefit over placebo
Side effects: aggression, agitation, sexual arousal, poor sleep, poor appetite
Glutaminergic & Dopaminergic interactions in Neostriatum are the focus of research in: schizophrenia, OCD, SIB, aggression Lamotrigine & Amantadine are under research
Nonestablished Treatments Various diets, regimens of vitamins, minerals, nutritional supplements, megavitamin therapy, B6 with Mg, gluten-free, yeast-free, casein-free diets,… No empirical study has support these treatments
Legal Issues All children with disabilities have to receive a free, appropriate public education in the least restrictive environment Reasonable accommodation have to be made for the employment of adults with disabilities
Individualized family service plan (IFSP)
0-3 year Child needs: Physical, motor, cognitive, linguistic, social-emotional evaluations Center-based or home-based early intervention services (a set amount hours/week)
Family needs: Support, financial assistance, information
3-21 years Child needs: Evaluation, educational plan (referral or individualized) School system: Legal process of evaluation & placement Special arts or athletic activities (special Olympics) Scholarship for adolescent with some disabilities (deafness, blindness,…)
Family needs: Support, financial assistant, information
21 years < Parents can no longer serve as offspring’s legal guardians Parents & offspring have major say concerning whether residential or work placement are appropriate
Offspring needs: Residential services, work
Family needs: Support, information, guardianship issues
