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Bilateral lesions and psychomotor seizures further

increase the risk of psychiatric disorder.

"Soft" Neurological signs such as non-specific EEG

changes, choreoathetoid movements of the outstretched

hand and clumsiness are common in the generalpopulation. They indicate some developmental delay

rather than brain damage. The presence of mild

overactivity does not indicate brain injury although it is

not uncommon to find neurological soft signs inhyperactive children.

Psychiatric disorder among brain damaged children is

composed of all forms of childhood psychiatric disorder,

mainly conduct disorders and emotional disorders. No

disorder or special syndrome is typical of brain damage.

However, some rare psychiatric disorders show a special

relationship with brain injury. Such conditions include

disintegrative psychosis, temporal lobe epilepsy and

infantile autism (about one-third of cases)

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Hyperactivity in general is not more common in a braininjured population, though the rare condition of

hyperkinetic syndrome is usually associated with

evidence of brain injury.

Children with brain damage have a higher rate ofreading retardation. In some measure this may reflect

missed schooling but can also result from cognitive

handicap. Among non brain-injured children specific

reading difficulties showed a marked association with

conduct disorder.

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PSYCHIATRIC ASPECTS OF MENTAL HANDICAP

Any classification of mental handicap should include the

criteria of social competence and functioning as well as thelevel of I.Q. For example, 10-20% of those with an I.Q.below 50 can become economically independent. Generally,however, mental handicap is divided into three categories:mild (I.Q. 70-85), moderate (I.Q. 50-70), and severe (I.Q.

below 50).Traditionally, the child psychiatrist's role has been only toassist in the identification of cases, which are then handedover to the psychiatrist in a mental handicap. With theacknowledgement that mentally handicapped children dosuffer from the same disorders that non handicappedchildren show, this has started to change. In fact,handicapped children are more vulnerable to psychiatricdisorders.

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Prevalence of psychiatric disorders

Among children aged 5-15 years, 3.1 per 1000 are

severely retarded. The rate of psychiatric disorder as

assessed by standard interviews is 50%, and byquestionnaires answered by teachers is 42% and by

questionnaires answered by parents is 30%. This

compares with 7% in the general children population.

The rate of disorder vary inversely with the I.Q. level, sothat children of superior intelligence showed less

disturbance than those of lower intelligence. There are

no links between mental handicap and any specific

disorder, although some disorders are more common

than others. The rate of disorder increases significantlyif there is physical handicap as well.

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Types of Disorders

The whole range of childhood disorders can be seen inmentally handicapped children. Among the severely

handicapped 13% show psychoses, 12% hyperkinetic

syndrome, 9% conduct disorders, 5% stereotypies, and

3% emotional disorders.

Mechanisms of Operation

It is imperative to know the way a psychiatric disorder

develops in a mentally handicapped child as this will

affect any treatment plans that might be considered. Forexample, if the psychiatric disorder is caused by an

organic factor that is also the cause of handicap then

one would need to primarily tackle that factor rather

than get involved in rehabilitation. The most likelymechanisms are the following:

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1. Organic brain dysfunction causing handicap as well as

psychiatric disorder. There is a great susceptibility of

children with organic brain dysfunction to psychiatricdisorder. All children with an I.Q. below 50 as well as

20-25% of those who are mildly handicapped show

demonstrable organic brain disease. Behavioural

improvement has been reported to follow surgicaltreatment of epileptic children.

2. Social factors, especially rejection, playing part in the

genesis of psychiatric disorders. The reaction of the

parents and the display of hostility in attitude towards the

handicapped child will certainly have an adverse effect

on the child's emotional or behavioural state.

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Handicapped children are not easily chosen as friends and

this sense of social isolation is sometimes compounded

by adverse temperamental characters such as poor

adaptability to new situations which in itself causes a

feeling of frustration in the parents. All these factors

make it possible for the child to be rejected and more

isolated. Rejection and social isolation are well knownfactors in causing psychiatric morbidity.

3. Mentally handicapped children can be affected by the

same factors that affect children of normal I.Q. and lead

to psychiatric disorder. Such factors include emotional

deprivation, genetic factors, and adverse social

environment.

b h i l di t b i ht i i t f th

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behavioural disturbances might originate from the poor

quality of care in those institutions. It seems that the

main issue is that these children need stimulation and

an opportunity to establish and develop lasting

relationships, without which they are more vulnerable topsychiatric disorder.

5. Specific developmental delays are common in

handicapped children. For example, learning difficulty,

speech delay, delay in acquiring social skills etc.. Achild who is mildly handicapped finds it difficult to cope

with the demands of a normal school, thus triggering a

sense of frustration and anger that is often expressed

by aggressiveness, truancy or some other unacceptable

behaviour.6. It is unlikely that emotional or behavioural disorders

lead to mental handicap. However, schizophrenic

children might find it difficult to learn, thus leading to

relatively lower scores on intelligence testing.

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A ti

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Autism

The association here is well documented. The distribution of I.Q.among autistic children was as follows:

below 50 40%

50-69 30% above 70 20%

Many other handicapped children do not show the full syndrome,but they show what has been termed 'autistic features' or 'atypicalautism'. Like autistics, mentally handicapped children are

particularly prone to develop epilepsy in adolescence or earlyadult life.

Communication difficulties

There is a high rate of sensory defects in mentally handicappedchildren, such as deafness or blindness. From this follows that

such children are predisposed to communication difficultiesespecially language problems. In such instances it is important tonote that such problems as speech delay are part of the generalretardation rather than being a specific delay. Communicationdifficulties commonly lead to learning difficulty which in turn mightmake the handicapped child seem to be worse than he/sheactually is. For a detailed account see (Psychotic Disorders).

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Stereotypies

Up to 40% of handicapped children under the age of 16show stereotyped behaviour. The most common repetitive

movements are rocking of the body and head banging.They are thought to be self stimulating movements andhappen when the child is in an environment that lacksstimulation. Sensory deficits such as blindness andassociated physical handicap make it more likely for ahandicapped child to show stereotyped behaviour.

Self mutilation

Several conditions are associated with self mutilationwhere the child bites himself or chew his lips or bites hisfingers down to the bone etc. About 15% of handicappedchildren deliberately injure themselves. Self mutilation hasbeen described in de Lange Syndrome; a conditionassociated with severe mental handicap. It is also seen inthe Lesch-Nyhan Syndrome (Infantile hyperuraecimia).Some autistic children tend to do the same in response tounwelcome change in their environment.

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Other psychiatric Disorders

Handicapped children are also exposed to the samedisorders that affect non-handicapped children. The

difference is that handicapped children present with slightlydifferent features, because of their deficiencies incommunicative, cognitive and intellectual development. Forexample, the diagnosis of schizophrenia becomes difficultand characterised by childish, silly behaviour, and thought

disorder particularly poverty of thought. Hallucinations areprimitive in nature and motor symptoms are commonespecially stereotypes and mannerisms. Manic-depressiveillness is uncommon in handicapped children, especiallybefore puberty.