Developmental Milestones and Additional Disabilities in Children attending ESN/M School in Dammam, Saudi Arabia.

Information about the extent of additional disabilities presented and experienced by the mentally retarded children is essential for proper health services planning for this group.The objective of this case-control study was to identify the developmental milestones and additional disabilities of mildly mentally retarded male children. Sixty-nine parents of mildly mentally retarded male children (MMR group) and a similar number of matched parents of normal male children (control group) were interviewed and a questionnaire was completed.Generally, the MMR group children smiled, sat, walked, talked and became continent for urine and bowel significantly later than the control group. Additional disabilities in the children of the MMR group were in the form of speech (65%), visual (28%), limb weakness (20%), hearing (16%), convulsive disorder (15%) and other disabilities (10%).Well structured health education and I.Q. screening programs were recommended for early detection of mental retardation and subsequent entry to special education. Institutes for mentally retarded children in the Kingdom need to be better vocationally equipped. The role of Family and Community Physicians in early detection and management was also emphasized.

INTRODUCTION

Although mental retardation in children has been known since biblical times, it was not before the nineteenth century that the diagnosis of “mental retardation” had therapeutic implications1. This movement for detection of mental retardation at the earliest possible time was based on a belief in the benefits of early intervention23

The recognition of developmental motor milestones delay may lead to earlier detection of mental retardation before cognitive delay becomes clear.1 Hence, failure to achieve an age - appropriate developmental milestone is of major concern.

Additional disabilities which commonly coexist with mental retardation are of multiplicative rather than additive effect4. For this reason, mental retardation consumes more professional and financial resources than any other disabling condition56. Information about the extent of additional disabilities presented and experienced by the mentally retarded children is of great importance. This information appears to be essential for proper planning and prioritizing the need for services of a diagnostic, treatment, preventive and research nature.

POPULATION AND METHODS

The study population consisted of 72 male children aged 5-15 years attending an education-ally subnormal/mental (ESN/M) school in Dammam City, Saudi Arabia, and their parents. An equal group of normal children, attending regular schools, and their parents were selected randomly as controls. Matching was based on age, residence, nationality and socio-economic class of the family. Three parents (4%) from the MMR group declined to participate for unknown reasons when seen at home. All fathers of the 138 children were invited by letter to take part in the study. The letter also included questions concerning the variables to be matched for which were necessary for selecting the best controls.

ESN/M schools are essentially day schools providing care for children who failed to progress satisfactorily in normal schools. For the child to be accepted in the institute (inclusion criteria) he has to fulfill the following:

Have an I.Q. in the range of 50-75 according to the psychological tests conducted by the psychological centre of the institute.

The child has to pass a medical examination to ensure being free from any handicaps which may hinder maximum benefit from the educational programmes.

The age of the child should be between 4-15 years.

The mean I.Q. score of the study group's children was 57.4. Geographically, the ESN/M school involved pupils from cities of Dammam, Sehat, Qatif, Al-Hasa and a few other villages. However, in view of their scattered areas of origin, shortage of time and limitation of resources, it was thought appropriate to cover only the children living in Dammam, Qatif and Sehat.

Information was collected by pre-trained interviewers using pretested and precoded questionnaires through pre-arranged home visits to parents. If there was no reply at the first visit, a second was arranged. The information obtained included personal data of the parents and past maternal medical history (pre-natal, natal, and post-natal), milestones of the child and associated handicaps. The social history (family income, level of education, occupation of the head of the family) was also enquired about.

SOCIO-ECONOMIC CLASS STRATIFICATION

In view of the absence of local socio-economic class criteria, families were divided into three strata (upper, middle, and low classes) according to the socio-economic class criteria used.7 The used criteria in this study had the advantage of measuring more than one variable (education, occupation and family income). The investigators had to modify these criteria to make it finer for better selection of controls. However, such criteria were standardized originally in communities different from the one targeted by this study.

The level of socio-economic class would be the result of adding A+B+C.

The scores and socio-economic classes were as follows:

Level 1: Upper socio-economic class 7+7+7=21

Level 2: Middle socio-economic class 9 - 20

Level 3: Low socio-economic class 3 - 8

To make finer selection of controls, this final score was also considered for matching purposes.

Data analysis was performed using the SPSS/PC+ Statistical Package. Appropriate tests were used in data analysis.

RESULTS

A. Differences in developmental milestones

Table 2 shows the differences in developmental milestones between children in the MMR and in the control groups. The mentally retarded group had a significant delay in any given milestone as compared to their controls. The mean age at discovery of mental retardation by the family was 48.7 months (SE = 4.4), while that when first institutioned was 9.2 years (SE = 0.2).

Table - 2

Comparison of Mean Milestones Age between MMR and Control Groups

The mean period of regular governmental schooling in years spent by the retarded child before his family decided to shift him to special education was 3.1 years.

Families from the low socio-economic class in the MMR group discovered the retardation of their children significantly later than families from the middle socio-economic class (P < 0.048).

B. Additional Disabilities.

Mothers of the MMR group indicated additional disabilities associated with mental retardation from which their children suffer. Table 3 shows that 19 children (28%) of the MMR children suffered different forms of visual disabilities ranging from errors of refraction to squints which are either uni or bilateral requiring medical attention. Forty five (65%) suffered from some form of speech disabilities which ranged from a simple delay in normal speech acquisition to difficulties in verbal pronunciation of one or more letters requiring speech therapy. Fourteen (20%) suffered from some kind of limb weakness, whether in the upper or lower limbs, requiring physiotherapy. Eleven children (16%) suffered some degree of hearing disability requiring aids, and 10 children (15%) suffered a form of epileptic seizures requiring medical treatment. Also 7 children (10%) suffered other forms of disabilities usually secondary to congenital malformations (polydactly, synedactly, cleftlips etc..).

Table - 3

Additional Disabilities (MMR Group)

DISCUSSION

In this study, the developmental milestone ages of the mildly mentally retarded children were shown to lag behind that of the normal children, this was also reported by Matsuishit8. Generally, for children similar to our MMR group sample, delay in a specific milestone age more than that of the control group should raise concern with both the mother of that child and the treating physician of the child if early diagnosis and management is to be instituted.

Many evaluation schemes based upon well child visits occurring at different ages of development have been already developed and used19–11 However, since milestones vary with different communities and cultures1, a need for a similar Saudi national evaluation scheme arises. It was shown that if delays in both language and problem solving exist, then mental retardation is likely. Confirmation of the diagnosis by the standard psychological instruments, that is Stanford Binet, Vineland Scale of Social Maturity will help in providing a measure of the child's cognitive and adaptive abilities1.

It was interesting to find that inspite of the significant delay in developmental milestones in the study group's children, they were instituted relatively late by their families. Similar to what was reported by other investigators12. Socio-economic class of the family played a role in the early discovery of retardation and subsequent early institution.

The rate of epilepsy in our study sample was relatively less than that reported locally by other investigators. Haque13 reported a rate of 25%, Melha and Rajeh14 reported a rate close to that of Haque's where 22% of their studied sample had mental retardation associated with seizure. However, in the U.S. Munro et al reported figures close to ours where 15 to 18 percent of their studied sample had epilepsy15. Another study quoted by the same reference15 showed that 16.4% of the mentally retarded children had experienced seizure as compared to only 1.4% of non-retarded control group.

Visual disability in our sample formed 28% of the total study group sample which was higher than that reported by other investigators such as Oregan (4.69%) and Levinson (2.3%) as quoted by Kiely16 and Munro et a115 respectively.

Speech and language defects on the other hand were found to be the most prevalent form of handicap in our study group with a rate of 65.2%. This rate seems to be high when compared with other national studies such as Haque13 who reported a rate of 10% or with other international studies such as Oregon reported by Kiely16 who reported a rate of 30.92%. However, Reynolds and Reynolds17 reported higher rates (51.2%) of speech impairment among the mentally retarded population.

Hearing disability with a rate of 16% in our study was less than the 20.1% reported by Haque13 but higher than what was reported by Stewart (10%)4 and Lloyd (10-15%) as quoted by Munro et a115. This discrepancy between different studies reporting different rates could be due to many reasons. These include different populations, sampling procedures, and different methodologies. However, it is worth mentioning that in our MMR group only children with minor handicaps other than being mildly mentally retarded would be accepted to be admitted in the institutes for the mentally retarded, so as not to hinder maximum benefit from the educational programmes. Hence, rates of additional handicaps in our study only reflect those children under study.

Early entry to special education is recommended for children with mental retardation. However, this necessitates early detection and diagnosis of mental retardation in children through well structured health education and I.Q. screening programs. Well planned health education programs should be started by primary health care centers in co-ordination and integration with the other concerned institutions. Such programs should aim at increasing public awareness towards the problem of mental retardation in children and its features. These programs will also increase public awareness of the available services to the mentally retarded children and their families and how these services are provided, when and by whom. Special attention concerning early diagnosis should be directed towards socially disadvantaged families. Larger scale future studies on the subject of mental retardation in children should be encouraged. Areas of related interests to mental retardation in children such as national developmental milestones scheme can be developed. Family and Community physicians should be involved in the early diagnosis and care of mentally retarded children and their families. Hence, training programmes in family and community medicine should include periods of exposure to ensure such experience.

Special education institutes for mentally retarded children should be equipped with facilities, staff and vocational training programs as to meet their role.

Table - 1

Criteria for Socio-Economic Class Stratification