Intellectual disability in children

1. Intellectual Disability
in Children
Definition, Epidemiology, Etiology, Clinical Features,
Diagnosis, Assessment, Management, Prognosis and Prevention
Prof. Imran Iqbal
Fellowship in Pediatric Neurology (Australia)
Prof of Paediatrics (2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

2. (God Almighty speaking to Prophet Muhammad (PBUH)
Say, “It is He who created and nurtured you;
and given you the hearing, the vision, and the thinking.
But rarely do you pay gratitude.”
The Holy Quran; surah Al-Mulk 67:23
In the name of Our Creator Allah, the most Gracious, the most Merciful

3. CNS

4. Brain

5. Our perceptions and Movements

6. Evaluation
of the Child with
Neurological Symptoms

7. CNS – Abnormal Symptoms
• Convulsions
• Altered Consciousness
• Delayed development
• Intellectual handicap
• Speech problem
• Motor weakness / Walking problem
• Sensory changes
• Headache
• Unable to see / listen

8. History – Ask about Symptoms
• Neurological Symptoms –
• Onset
• Frequency
• Severity
• Progression
• Birth history
• Development history
• Family history

9. CNS – Abnormal Signs
• Developmental milestones (in relation to age)
• Impaired Conscious level (GCS)
• Convulsions
• Intellectual impairment (retardation / handicap)
• Motor weakness / Paralysis / Paresis
• Abnormal gait
• Abnormal movements
• Visual impairment
• Auditory impairment

10. CNS Examination
in Children

11. Examination of CNS in Children
• OBSERVE – observe the child
• General Physical Examination
• Developmental Examination
• NEUROLOGICAL EXAMINATION –
• Higher Mental Functions
• Cranial Nerves
• Motor System
• Sensory system
• Skull and Spine
• SOMI

12. Developmental Examination

13. Child Development

14. Areas of Development
 Posture and locomotion
 Vision and manipulation
 Hearing and speech
 Personal and social

15. Areas of Development
 Posture and locomotion
 Vision and manipulation
 Hearing and speech
 Personal and social

16. Milestones of Development
Posture and locomotion
 3 months – Head control
 6 months – Roll over
 9 months -– sit without support
 12 months – stand / walk held

17. Milestones of Development
Vision and manipulation (eye – hand coordination)
 3 mo – Eyes fix and follow
 6 mo – Hand approach to hold
 9 mo -– Finger grasp
 12 mo – Release object in examiner’s hand

18. Milestones of Development
Hearing and Speech
 3 mo – Response to voice
 6 mo – Turn to sound
 9 mo -– Babbles
 12 mo – One word

19. Milestones of Development
Personal Social
 3 mo – Smile
 6 mo – Shows likes and dislikes
 9 mo – Stranger anxiety
 12 mo – Waves bye-bye

20. Neurological Examination

21. NEUROLOGICAL EXAMINATION
• Higher Mental Functions
• Cranial Nerves
• Motor System
• Sensory system
• Skull and Spine
• SOMI

22. Higher Mental Functions
• Conscious Level (Glasgow Coma Scale)
• Recognition and Response
• Behavior and activity
• Speech
• Memory

23. Cranial Nerves
• Visual focusing and following
• Light reflex
• Facial Movements
• Response to sound
• Sucking and Swallowing
• Palate movement and Gag reflex

24. Motor System
• Presence of spontaneous voluntary movements in
infant
• Size and Nutrition of muscles
• Tone
• Power
• Deep Tendon Reflexes
• Planter Reflex
• Gait
• Co-ordination
• Involuntary Movements

25. Sensory System
• Touch
• Pain
• Temperature
• Position
• Vibration

26. Skull & Spine
• Shape of skull
• Anterior fontanel
• Occipito-frontal Circumference (OFC)
• Spine – Curvature, local swelling

27. SOMI – Signs of Meningeal Irritation
• Bulging Anterior fontanel
• Neck rigidity
• Kernig's sign
• Brudzinski's sign

28. Clinical Presentation
of
CNS diseases

29. CNS disease – Clinical Presentation
• Seizures / Convulsions / Fits
• Impaired Conscious level
• Developmental delay
• Intellectual handicap
• Neurological Paralysis / Paresis (motor weakness )
• Neuromuscular disorders / Hypotonia
• Movement disorders
• Headache
• Regression of acquired milestones
• Behaviour problems

30. Developmental delay
and
Intellectual handicap

31. Developmental delay / Intellectual handicap
Etiology
• Perinatal Brain Damage (HIE) (Hypoxic Ischemic
Encephalopathy)
• Postnatal Brain damage (e.g. Meningitis)
• Cerebral Malformations (e.g. agenesis of corpus callosum)
• Chromosomal disorders (e.g. Down syndrome)
• Genetic syndromes (single gene defects)
• Degenerative brain diseases (Leukodystrophy)
• Hypothyroidism (Cretinism)
• Severe Systemic Diseases (cardiac, renal, malnutrition)

32. Developmental delay / Intellectual handicap
Clinical Presentation
• Cerebral Palsy
• Delayed development
• Intellectual disability

33. Intellectual Disability
in Children
Definition, Etiology, Epidemiology,
Clinical Features, Diagnosis, Management

34. Intellectual Disability
Definition
• Intellectual Disability is a neuro-developmental disorder with
delayed development and impaired intellectual functions
• There is significant impairment in –
 general intellectual function
 conceptual skills
 social skills
 practical skills
 adaptive behavior
• Intelligence quotient (IQ) scores are < 70

35. Intellectual Disability
Impairment of Intellectual Functions
• General intellectual function – reasoning, learning, problem
solving
• Conceptual skills – language, reading, writing, time, number
concepts, and self-direction
• Social skills – interpersonal skills, social responsibility, obeying
laws
• Practical skills – activities of daily living (dressing, feeding,
toileting/bathing, mobility)
• Adaptive behavior – functions of living (e.g., housework,
managing money, taking medication, shopping, using phone)

36. Intellectual Disability
Etiology
• Cerebral Malformations (e.g. agenesis of corpus callosum)
• Chromosomal disorders (e.g. Down syndrome)
• Genetic syndromes (single gene defects)
• Perinatal Brain Damage (HIE) (Hypoxic Ischemic
Encephalopathy)
• Postnatal Brain damage (e.g. Meningitis)
• Hypothyroidism (Cretinism)
• Nutritional disorders – severe malnutrition
• Child abuse and neglect

37. Intellectual Disability
Epidemiology
• Incidence: 2.5 / 100 children
• Classification
• Mild – IQ score = 50 - 70
• Severe – IQ score < 50

38. Intellectual Disability
Investigations
Competencies
• Developmental evaluation – IQ
• Eyes / Vision evaluation
• Hearing evaluation
• Psychologist evaluation
• Teacher evaluation
Etiology
• CT / MRI Brain
• EEG – seizures
• Karyotype
• Metabolic studies
• Genetic studies – Whole Exome Sequencing (WES)
– Whole Genome Sequencing (WGS)

39. Intellectual Disability
Management
• Family support
• Special education
• Behavior management
• Medications

40. UN Convention on the Rights of the Child
1989
“A disabled child has the right to enjoy
a full and decent life,
in conditions which
ensure dignity,
promote self-reliance
and
facilitate the child’s active participation
in the community.”

41. Prof Imran Iqbal
Fellowship Pediatric Neurology-1991
Royal Children Hospital, Melbourne, Australia