1.2 Unit Learning Outcomes

Upon completion of this unit, you will be able to: 1.     Discuss the management of children with special education needs 2.     Describe the management of conduct/opposition disorder 3.     Explain the psychological effects of child abuse

1.3 Children with Special Education Needs

Children with intellectual disability and giftedness have special education needs because they fall on either extreme end of the intelligence spectrum.  No matter how we choose to define and assess intelligence, it is true that there will be a wide range of individual differences. For example, intelligence tests compare people’s scores to averages of others of the same chronological age, so most people by definition show average intelligence scores. What about those whose Intelligence Quotient (IQ) scores are significantly below average (intellectual disability) or above average (gifted)? What outcomes are common for these individuals? This section will specifically explore children with intellectual disabilities and learning problems.

The three categories of children with special education needs that will be covered are:

• Intellectual Disability
• Attention Deficit Hyperactivity Disorder (ADHD)
• Autism Spectrum Disorder

Let us start by looking at intellectual disability.

1.3.1 Intellectual Disability

What is intellectual disability?

This is a disorder in which a person’s overall intellectual functioning is well below average, with an intelligence quotient (IQ) score of around 70 or less. Individuals with intellectual disability are significantly impaired in their ability to cope with common life demands and lack certain daily living skills expected of people in their age group and culture.  The impairment may interfere with learning, communication, self-care, independent living, social interaction, play, work, and safety. Intellectual disability appears in childhood, before age 18.

The American Psychiatric Association’s (APA, 2014) Diagnostic Manual Five (V) has substituted mental retardation with the term intellectual disability. In the United Kingdom, the term mental retardation is used interchangeably with the term ‘learning disability’.

Incidence of Intellectual Disability

About 1% of the general population has intellectual disability (APA, 2014) although some estimate the range is as high as 3% (ICD 10, 2010). Intellectual disability is slightly more common in males than in females. It occurs in people of all racial, ethnic, education, and economic backgrounds.

Degrees of Severity

There are four degrees of severity of Intellectual disability based on IQ score:

• Mild disability (retardation) (IQ range 50-55 to about 70).
• Moderate disability (IQ range 35-40 to 50-55).
• Severe disability (IQ range 20-25 to 35-40).
• Profound disability (IQ level below 20-25).

People of average intelligence, score anywhere from about 90 to 110 on IQ tests.

Let us look at each degree of severity, starting with mild disability.

Mild Disability

Children with mild disability often cannot be distinguished from normal children until they attend school. They may be labelled as slow learners by their teachers. Although they learn slower than the average child does, they can develop academic skills equivalent to the sixth-grade level. As adults, they can work and live in the community if helped when they experience unusual social or economic stress. Some may marry and have children.

Moderate Disability

Children with moderate disability can progress to about the second-grade level in academic skills. By adolescence, they usually have good self-care skills such as eating, dressing, and going to the bathroom and can perform simple tasks. As adults, most can work at unskilled or semiskilled jobs with supervision.

Severe Disability

Severe disability affects 3 to 4% of intellectually disabled individuals. Severely disabled individuals may learn to talk during childhood and develop basic self-care skills. In adulthood, they can perform simple tasks with close supervision. They often live in group homes or with their families.

Profound Disability

About 1 to 2% of disabled people have profound intellectual disability and require constant care. Profoundly disabled individuals can understand some language, but they have little ability to talk. They often have a neurological condition that accounts for their disability.

Causes of Intellectual Disability

Having looked at the different types of intellectual disabilities, what do you think causes intellectual disability in children? Take two minutes to think about it and then complete the activity below.

Activity 1.1 In your notebook, write down two causes of intellectual disability in children.

Well done! Compare your answers with the causes listed below.

The causes of intellectual disability are:

• Genetic conditions.

• Disorders that occur as a foetus develops during pregnancy.
• Problems during or after birth.

Let’s look at each course in turn starting with genetic conditions.

Genetic conditions

Chromosomal disorders such as Down syndrome are an example of genetic conditions that can cause intellectual disability. Down syndrome occurs when people inherit all or part of an extra copy of a pair of chromosomes known together as chromosome 21. Although regarded as genetic disorders, chromosomal disorders are not necessarily inherited. Both parents may have normal genes, with the defect resulting from a random error when chromosomes reproduce.

Disorders that occur as a foetus develops during pregnancy

A variety of problems during a woman’s pregnancy can cause her child’s intellectual disability.

• Malnutrition
• Mother’s use of alcohol or drugs. Foetal alcohol syndrome results from excessive consumption of alcohol during pregnancy, including premature birth, very low birth weight, and stresses to the foetus such as deprivation of oxygen.
• Environmental toxins such as lead and mercury
• Viral infections, including rubella and cytomegalovirus
• Untreated diseases such as diabetes mellitus.

Problems that occur during or after birth

Infectious diseases during childhood, which are easily preventable through immunisation, also can cause intellectual disability when they result in complications. For example, measles, chicken pox, and whooping cough may lead to encephalitis and meningitis, which can damage the brain.

• Physical trauma to the brain can also cause intellectual disability.
• Brain damage may result from accidental blows to the head.
• Near drowning.
• Severe child abuse.
• Childhood exposure to toxins such as lead and mercury.
• Experts believe that poverty and a lack of stimulation during infancy and early childhood can be factors for intellectual disability. Children raised in poor environments are more likely to experience malnutrition, lack of routine medical care, and environmental health hazards.

 

Management of Children with Intellectual Disabilities

Care and support should always be provided within a therapeutic environment or an appropriate setting. Support may be general or specific.

General Support

Care is provided by the child’s usual caregivers such as their parents, relatives and sometimes even the hired help (nanny or house cleaner).    Other health workers such as physiotherapists and community nurses promote a normal environment by:

• Encouraging care to take place at home,
• Integrating children into mainstream schools in cases where the degree of disability is only mild or moderate.
• Use of local community resources. For example, whatever assets are available in that community that could be used to care for these children such as physiotherapy or meeting in a central accessible point once a week for two hours.

Specific Support

Special support addresses particular needs. These needs include special education, parental support groups, and maladaptive (abnormal) behaviours. Often, environments that are more specialised are necessary if disabilities are too severe to manage with standard community resources. Such disabilities include severe and profound learning disability (LD), severe treatment resistant epilepsy, aggressiveness, co-morbid psychiatric disorder, respite placements.

Epilepsy and Intellectual disabilities

Epilepsy may occur in people with intellectual disabilities. It may begin at any age, and multiple forms may occur in the same individual. Frequent epileptic seizures may lead to (or worsen) permanent loss of intellectual functioning (acquired epileptic aphasia), progressive partial seizures.

Treatment

The treatment involves a neurologist and therefore the psychiatrist needs to work with other specialists. The choice of treatment will depend on:

• Accurate classification of the type of seizures or epilepsy.
• Possible drug interactions.
• Minimising side effects, especially cognitive impairment.

Prevention of Intellectual Disabilities

Intellectual disabilities can be prevented by:

1. Screening programs for at risk infants and children during under five clinics, antenatal care (ANC) and other children’s clinic, for example, by nurses and other health workers in paediatrics or neonatal clinics.
2. Adult screening tests can identify carriers of certain conditions before couples conceive a child.
3. Individuals and couples with a family history of mental retardation can seek genetic counselling to evaluate their own risks and need for screening.
4. Specialised laboratory tests, including amniocentesis, can detect Down syndrome and other genetic disorders in the early stages of pregnancy.
5. Proper prenatal care, avoidance of alcohol and drugs during pregnancy, and routine immunisation against measles and other childhood diseases can prevent some forms of retardation. This can be done by nurses working in such settings when these children are brought to ANC and under five clinics.

Treatment and Care of Children with Intellectual Disabilities

Children diagnosed with mild mental retardation may gradually develop new skills through early intervention and educational services.  As adults, they may function in everyday life at a level that no longer warrants a diagnosis of retardation.

All but the most profoundly disability people usually can best develop their full potential by living in the community.  Most people with mental retardation have the capacity to learn, advance intellectually, develop job and social skills, and become full participants in society. They may marry, have families, and be indistinguishable from other people.  In order to achieve their potential, mentally retarded children need special education and training, which ideally begins in infancy and continues until they establish an adult role.

The Role of a Nurse in Managing Children with Learning Disabilities

What do you think is the role of a nurse in managing a child with intellectual disability? Think about it for two minutes and then compete the activity below.

Activity 1.2 In your notebook, write down two roles of a nurse in the management of children with intellectual disabilities.

Well done! Compare your answers with what you read in the section below.

Psychological Care

It may take parents a long time to accept that their child is developing at a slower rate than other children in the same age group. They often go through a grieving process as they try to accept this reality. The length of this grieving process may vary depending on the psychological, social and medical support and expertise availed to them.   Absence or lack of adequate medical expertise, psychological and social support will without any doubt lead to inadequate care by the child’s caregivers or parents. The child might even be abused, sometimes unknowingly because of the denial, anger and depression that many parents experience. Children with intellectual disability are at risk of being harmed, because they are vulnerable.

Early Identification and Intervention

The nurse plays a role in the early identification of intellectual disabilities. The children they identify can receive the necessary care as soon as possible, since the brain has been known to grasp and learn skills better, at a tender age. In your role as a nurse, you should counsel the parents or caregivers and facilitate any additional services such as physiotherapy, medical and surgical interventions if needed, special education, and psychosocial support.

You should also facilitate any medical and surgical interventions, and provide primary, secondary and tertiary health services to improve the quality of life of children with learning disabilities.

Prevention of Intellectual Disability

The role of the nurse in preventing intellectual disability starts before pregnancy through  providing counselling and information, education and communication to prospective mothers about practices that can support a healthy pregnancy and baby.

During the antenatal period, the nurse provide measures that support a healthy pregnancy and normal growth and development of the foetus such as a good diet, treatment of any existing diseases in the mother and avoiding environmental hazards.

During labour and delivery, the midwife works to prevent birth asphyxia and trauma that can harm the foetus. They do this by employing frequent observations to quickly identify anything that could go wrong and continued alertness for any delays in labour.

In the postnatal period and during the early years of a child’s life, nurses and midwives ensure the child receives immunisations from childhood diseases that may lead to brain damage in according to the immunisation schedule. Nurses also ensure that other diseases like malaria are prevented and are promptly treated if they occur.

During adolescence, nurses advise parents and support them in caring for their adolescent children. This stage of life can involve experimentation and risky behaviour such as substance abuse, use of firearms, driving before they legal driving age, and unsafe sexual practices. These behaviours could put them at risk of accidents and diseases that might damage their brain thereby leading to intellectual disability.

Psychiatric Comorbidity in the Intellectually Disabled (ID) Population

Psychiatric comorbidity refers to the psychiatric problems that may be seen in a child with intellectual disability.

Psychiatric disorders occur more frequently in the intellectually disabled population than the general population. They include:

• Symptoms in severe intellectual disability include unexplained aggression, bizarre behaviours, mood lability, increased mannerisms and stereotypes.
• Bipolar affective disorder. Symptoms include hyperactivity, wandering, mutism, temper tantrums.
• Depressive disorder.
• Biological disorders are more marked, with diurnal variations. Suicidal thoughts / acts may occur in borderline to moderate intellectual disability.
• Anxiety disorders, obsessive compulsive disorder, attention deficit hyperactive disorder (ADHD), and personality disorder.

Behavioural Disorders and ‘Challenging’ Behaviour

These are pathological behaviours that are common in the ID population. They create a significant burden for parents / carers. They are:

• Antisocial behaviour- shouting, screaming, general noisiness, anal poking/faecal smearing (may reflect constipation), self-induced vomiting/choking, stealing.
• Aggressive outbursts – against persons or property.
• Self-injurious behaviour – skin picking, eye gouging, head banging, face beating (more common in severe/profound ID).
• Social withdrawal.
• Stereotypic behaviours (some of which may be injurious).
• Hyperactive disruptive behaviours.
• Repetitive communication disturbance.
• Anxiety fearfulness.

When these behaviours are particularly severe, they are often termed ‘challenging’. Management of children with intellectual disability happens while they continue to live in their homes. The best way to care for these children is to allow them to continue to be with their loved ones in a familiar and caring environment.

They need to be encouraged to work on their strengths or activities they are good at, with assistance from their caregivers. Caregivers and parents require counselling and social support from nurses to create a conducive environment for their intellectually disabled children. The nurse also plays a role in working with other members of the multidisciplinary team (psychiatrist, clinicians, neurologist, psychologist, sociologist, physiotherapist and surgeon) to deliver and facilitate psychosocial support for both the affected child and their caregiver.

Having looked at the role of a nurse in managing a child with intellectual disabilities, we will discuss the treatment modalities that can be employed in the next section.

Treatment Methods for Intellectual Disability

The different psychological therapies are administered by psychologists. Refer back to the course on Psychology in nursing to refresh your knowledge on the different psychological approaches. The nurse’s role in treatment involves should involves ensuring their patients receive their prescribed treatment, and even participating in the simpler treatment options such as behavioural and cognitive ones. These treatments work for children with mild and moderate intellectual disability because they are able to think and reason fairly well.

In this section, we will discuss the following treatment methods:

• Behavioural treatment
• Cognitive therapy
• Psychodynamic therapies
• Pharmacological treatments

Let us start by looking at behavioural treatment.

Behavioural Treatment

Behavioural treatment is based on operant conditioning. Behaviour may be shaped towards the desired result through rewarding small, achievable intermediate steps. In school, good behaviour can be rewarded with material items, privileges and ‘star’ charts, when a certain level is achieved.

This method may be used to help teach basic skills (feeding, dressing, toileting) and establish normal behaviour patterns (sleep), or more complex skills (social skills, relaxation techniques, assertive training).

It may also be used to alter maladaptive patterns of behaviour (inappropriate sexual behaviour, phobia).

Cognitive Therapy

Cognitions are thoughts or thinking patterns. These thinking patterns can become negative. For example, the child begins to think that they are not good enough to be alive, or that they cannot achieve anything in life, leading to poor self-esteem, anxiety and depression.

Cognitive therapy is treatment that is targeted at changing negative thoughts and replacing them with thoughts that increase the self- esteem (self-respect) of a person. When self -esteem is increased the behaviour will also improve and feelings of anger will be dealt with. This means that in the case of children with borderline, mild or moderate intellectual disability, cognitive approaches may be adapted for teaching of:

• Problem solving skills.
• Management of anxiety disorders.
• Dealing with issues of self -esteem.
• Anger management.
• Treatment of offending behaviours (for example, sex offenders).

Psychodynamic Therapies

Psychoanalysis is helpful in addressing issues of emotional development, relationships, and adjustments to life events (losses, disabilities, and bereavements). They range from basic supportive psychotherapy, to more complex group and family therapies. In psychoanalysis, the therapist uses probing and open -ended questions to bring out hidden feelings that are the cause of abnormal behaviour from the subconscious mind of a client. Such feelings originate from early traumatic childhood experiences. Once the patient becomes aware of these feelings with the help of the counsellor or therapist, they can work towards resolving them.

 Pharmacological Treatments

Refer to your notes on pharmacology for the actual names of the drugs, side effects, dosages, actions and nursing implications. The following treatments may be indicated:

• For children that need medication, the nurse should ensure they are reviewed regularly to maintain adequate supply of drugs and observe any side effects. Comorbid physical disorders (epilepsy, constipation, cerebral palsy) increase the need to monitor side effects.
• Antipsychotics are used to treat comorbid psychiatric disorders and acute behavioural disturbance, autistic disorders, self-injury, social withdrawal, ADHD and tic disorders.
• Antidepressants are effective in depression, obsessive compulsive disorder (OCD) , anxiety disorders, violence, self-injury, and ‘nonspecific’ distress.
• Anticonvulsants are used to treat underlying epilepsy and in episodes of difficulty in controlling movements.

 You have come to the end of this section on intellectual disability.