Neurological, Psychiatric, and Developmental Disorders Meeting the Challenge in the Developing World (2001) / Chapter Skim
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5 Developmental Disabilities
5 Developmental Disabilities
Pages 109-178
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From page 109... ...
Finally, these particular classes of disorder appeared to be strong candidates for cost-effective interventions, and therefore critical targets for reducing the overall burden of disease associated with brain disorders. It is hoped that future studies on other brain disorders of public health significance, such as Alzheimer's disease, injuries to the central nervous system, substance abuse, and posttraumatic stress disorder, will build on this initial effort.
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From page 110... ...
In most cases, direct correlations appear to exist between developed and developing countries. For example, many proven risk factors for stroke have been established in developed countries (such as hypertension, highfat and sodium diets, and diabetes)
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From page 112... ...
:and -various~-rim:arv health care models-. and: national
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From page 113... ...
Brief descriptions of the clinical features of each of the broad categories of developmental disability are provided below. It may be noted that children with developmental disabilities are often affected in multiple domains of function because of the nature and extent of brain impairment or increased susceptibility to other causes of disability (e.g., malnutrition, trauma, infection)
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From page 114... ...
1 F80.2 F90.0 F84 F8~F98 Source: [1] Cognitive Disabilities Cognitive disabilities in children include mental retardation as well as specific learning disabilities in children of normal intelligence.
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From page 115... ...
Individuals with cerebral palsy often have other disabilities as a result of concomitant insults to various areas of the brain. Such disabilities include mental retardation, leaning disabilities, epilepsy, language disorders, and behavioral problems.
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From page 116... ...
The optimal period for speech acquisition is the first 2 years of life; a child who does not speak by the age of 5~ will have difficulty developing intelligible speech thereafter. it is therefore important to screen young children for hearing impairment and to evaluate the hearing of a child who is suspected of having mental retardation or delay in speech development.
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From page 117... ...
The persistence of excess prevalence rates of developmental disabilities observed in low-income countries today is both a consequence of poverty and poor resource allocation and an impediment to future social and economic development. ' The most recent DALY figures in low- and middle-income countries for risk factors discussed in this chapter include HIV/AIDS, 5.5 percent; polio, 0.0 percent; measles, 2.4 percent; tetanus, 1.0 percent; meningitis, 0.4 percent; malaria, 3.1 percent; Japanese encephalitis, O percent; trachoma, O.lpercent; protein-energy malnutrition, 1.2 percent; iodine deficiency, 0.1 percent; vitamin A deficiency; 0.2 percent; anemias, 1.9 percent; road traffic accidents, 2.7 percent; homicide and violence, 1.6 percent; war, 1.7 percent.
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From page 118... ...
An additional problem in comparing prevalence studies from developing countries is that elevated infant and child mortality rates may curtail the prevalence of developmental disabilities in the population. If improvements in child survival are made without concomitant reductions in the occurrence of new cases of developmental disabilities, the result will be an increase in the population prevalence of disability due to the increased longevity of children with disabilities.~23-25]
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From page 119... ...
In developed countries, the prevalence of severe cognitive disability is consistently found to be in the range of 3 to 5 per l,OOO children. By contrast, the prevalence of severe cognitive disability in developing countries ranges from a low of 2.9 per 1,000 children in Beijing to a high of 22 per l,OOO in slum areas surrounding Lahore, Pakistan.
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From page 120... ...
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From page 121... ...
Studies in India have estimated that 80 million individuals suffer from some level of disabling hearing impairment.~51] A 1990 official survey of the handicapped in China reported 23.1 million hearing-impaired individuals among which six million suffered from profound hearing loss.~52]
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From page 122... ...
* urban population lo, =m m ~ m ~ ~ ~5 ~5 ·— to ~ ~ o Y In ~ ~ _ Sit ~ 111 o In FIGURE 5-2 Prevalence of Cerebral Palsy, a subtype of m otor deficits, in various countries Source: 16~68]
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From page 123... ...
FIGURE 5-3 Prevalence of Childhood blindness pe r 1 0 0 0 b irth s Source: t6073]
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From page 124... ...
More recent prevalence studies based on explicit diagnostic criteria and including Asperger's syndrome report a range of severity with overall prevalence as high as 4 per 1,000 children.~77] Similar studies of the prevalence of autistic disorders in developing countries could not be identified.
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From page 125... ...
A recent study in the United States revealed that 33 percent of the children observed with sickle-cell disese were functioning in the range of mild mental retardation.~83] In populations lacking effective contraception, family planning, and prenatal screening, the proportion of births to women over age 35 and the prevalence of Down syndrome are high.
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From page 126... ...
Deficient metabolism of phenylalanine causes accumulation, which if untreated leads to hyperphenylalaninaemia, progressive damage to the developing brain during the neonatal and postnatal periods, and severe mental retardation in most cases. In populations where newborn screening and dietary treatment for PKU are feasible (as discussed in the following section on interventions)
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From page 127... ...
Although iron deficiency may not be a sufficient cause of developmental disability, it contributes to the risk of such disability by lowering immunity, impairing fat and vitamin A absorption, impairing thyroid hormone transformation, increasing lead absorption, and increasing the risk for low birth weight.~1 1371:14] Evidence of direct, central nervous system effects of iron deficiency anemia during infancy was recently found in Chile.~115]
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From page 128... ...
Evidence regarding the independent effects of general nutrition on children's mental development suggests that nutritional changes from gestation through 6 months of age, as well as between 42 and 75 months of age, appear to produce no measurable effects on mental performance later in childhood.~126,128-132] Dietary supplementation of undernourished infants and children in Bogota between 6 and 36 months of age was followed by improved mental performance from 12 to 36 months, but follow-up beyond 36 months was not done.
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From page 129... ...
Congenital rubella can manifest with deafness, cataract and visual impairment, mental retardation, and failure to thrive. This cause of developmental disability has been virtually eliminated in successfully vaccinated populations, but epidemics of rubella continue to occur in some developing countries.~137139]
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From page 130... ...
with antiparasitics is believed to reduce the occurrence of hydrocephalus and cognitive sequelae, though even among treated infants the frequency of severe mental retardation in one follow-up study of infected infants was 21 percent.[l63] Postnatally acquired infections are important causes of developmental disabilities among children in low-income countries, where access to prophylaxis and treatment is often limited and delayed.
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From page 131... ...
Once established in the intestines, poliovirus can enter the blood stream and invade the central nervous system. As it multiplies, the virus destroys motor neurons and leads to irreversible paralysis.
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From page 132... ...
and tobacco smoke may also have detrimental effects on the developing nervous system.~200,201 ~ Perinatal and Neonatal Perinatal events such as preterm birth, low birth weight, intrauterine growth restriction, and birth asphyxia are associated with elevated risk of impaired physical, sensory, and mental development during infancy and childhood.~202] Many factors contribute to the elevated frequency of these events in low-income countries.
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From page 133... ...
Examples of such interventions are newborn screening for PKU, followed by dietary modifications, and emergency medical care for trauma. Genetic Factors Expansion of family planning and contraception to prevent unplanned births to women over age 35 is a cost-effective strategy for prevention of mental retardation, specifically of Down syndrome (trisomy 21)
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From page 134... ...
iodine deficiency is still a prevalent cause of developmental disability in many communities, and its elimination will require sustained efforts.~218j
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From page 135... ...
135 'H; Q it_ - d 1 _ 1~ hi rid_ \.
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From page 136... ...
Folic acid. Folic acid supplementation or fortification of the food supply is effective against neural tube defects, but only if the folate requirements of childbearing women are met periconceptionally or very eaily in pregnancy.
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From page 137... ...
Primary prevention of Haemophilus influenzoe Type b meningitis can be achieved by means of vaccination of all infants or by chemoprophylaxis following close contact with an affected child. Vaccination is the only practical method of preventing infection on a population level.
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From page 138... ...
However, measles continues to be a major contributor to childhood death and disease worldwide. Global eradication of this cause of developmental disability will require sustained efforts.
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From page 139... ...
Prenatal Care and Perinatal Services Several specific interventions discussed in other sections of this chapter that are effective in the primary prevention of developmental disabilities may be implemented through prenatal and perinatal services. These include prenatal and newborn screening and intervention, prevention and treatment of prenatal infections, and avoidance of teratogenic exposures during pregnancy.
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From page 140... ...
Secondary Prevention Opportunities abound for secondary prevention of developmental disabilities in low-income countries through early recognition of potentially disabling conditions and interventions aimed at preventing or minimizing disability. These include early identification and correction of vitamin A deficiency and other forms of malnutrition; PKU screening followed by dietary modifications; accurate and early detection and effective management of bacterial infections that can lead to meningitis or hearing loss [51,54~; effective treatment of malaria; provision of vision and hearing screening, eye and ear care, and refractive and hearing aid services at the primary health care level 15,243-249; improved access to emergency medical services to prevent trauma-associated disability; and educational interventions to overcome specific learning and sensory disabilities.[51,54,250 254]
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From page 141... ...
. Early identification and special educational interventions to improve outcomes for children with cognitive disabilities, including specific learning and sensory disabilities.
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From page 142... ...
In many cases, appropriate educational rehabilitation in adults with such conditions as mild mental retardation can vastly increase their ability to function independently and contribute to family and community responsibilities. Models for Rehabilitation Multiple models are feasible and may be necessary for providing rehabilitation services to children with developmental disabilities and their families in settings where professional resources are extremely limited.
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From page 143... ...
Box 6-1 describes an example of a CBR program in Jamaica. ~~ BOX- ~~CommuniW-Based'.Rehabilitatipp~'n Jamaica.
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From page 144... ...
Promotion of this approach began internationally following agreements such as the UNESCO Declaration of Education for All, which stipulates that all countries have a responsibility to provide equal access to education to children with disabilities as an integral part of the education system.~266] it appears likely that CBR and inclusive education are mutually reinforcing, since CBR programs need to place children in regular schools, and teachers find support from CBR workers when they accept children with disabilities.~267]
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From page 145... ...
:There :are special classes for chi dren with cerebral palsy,'speech and lang~uage problems, and befiaviorat piD.e.~ms such: as~:autisrn - .sid a ~| ~sheltered-workshop-, adolescent-boys and gifis~:are taught ca~rpentry,~weav -- : : iog, ~and ~painting~. ~:An a:ffi-l:iated school:~servir~q :both: disabled ~and:nondisabled -ch'ldrenwasestablish~ed~to:p mo ~mai :i g.: -- ~-::~- ~ -- :~:~-:~-~:~: ~:: ~ -~ - :~ :~ -- ~ ~Dham~ra~i- Ru~ra:l- Sc:hool:.
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From page 146... ...
In keeping with its policy of integrating disabled children into mainstream schools, the ministry has also created resource units in both primary and secondary schools for children with moderate to severe learning disabilities and visual and hearing impairments.~273] Yet while this system provides good and expanding coverage, the program has not met the demand for places in special education.~274]
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From page 147... ...
Rehabilitation villages have been constructed in a number of rural hospitals, where disabled children and their caregivers can be accommodated for group activities and workshops. Primary Health Care Models and National Strategies.
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From page 149... ...
Under the Education Ministry, a Department of Special Education within the University of Dhaka was founded in 1995 to train teachers of children with sensory and intellectual disabilities (see Box 5-2~. Under the Health Ministry, a Rehabilitation institute and Hospital for the Disabled provides treatment and rehabilitation services for the physically and orthopedically disabled.
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From page 150... ...
'Al' diploma cou'rse; in: develo'pmental'the~ apy-is-now,'' being:planned in.~.coJlaboratior, with the. Institute,'.:of Special Educe ' cation, Bangiadesh~ .Protibondhi Foundation (see Box.'~5-2?
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From page 152... ...
At present, 80 organizations are active members of the forum. And the Bangladesh Scouts and Girls in Scouting have established open groups for disabled children so that even those children not enrolled in regular schools can form groups to become members.
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From page 153... ...
Inclusive educational policies at both the national and local levels should be implemented to ensure that all children, including those with disabilities, have access to appropriate schooling. Resources must be provided in developing countries for special training and support of teachers in the recognition and teaching of children with developmental disabilities, including mental retardation and specific learning disabilities.
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From page 154... ...
identification and treatment; and the availability of laboratory facilities for testing and confirmation, genetic counseling, treatment, and followup services. Newborn screening requires a government commitment and regulation and should include all births unless clear risk categories can be identified and subpopulations targeted.
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From page 155... ...
These programs should include pediatrics, pediatric neurology, neonatology, psychiatry, optometry, ophthalmology, obstetrics, midwifery, infectious disease control, diagnostic imaging, and nutrition. Special education training programs · Such programs are required to train cadres of teachers working in lowincome countries in the recognition and teaching of children with special educational needs due to low cognitive abilities; specific learning disabilities; and vision, hearing, and behavioral disorders.
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From page 156... ...
In the longer term, research efforts might focus on the development of strategies for prevention. Training initiatives should be given priority to provide a foundation of skilled staff that can support the development of rehabilitation services.
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From page 157... ...
that provide immunization; nutrition and growth assessment; developmental, vision, and hearing screening; health education; and identification of risk factors for disabilities. Children are seen by primary health workers in these clinics regularly and frequently for monitoring and treatment.
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From page 158... ...
Those systems must in turn be linked to and supported by secondary and tertiary medical services. Additionally, to provide appropriate guidance to those in need of rehabilitation services for developmental disabilities, primary and maternal and child health care systems should be linked to local rehabilitation programs.
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From page 159... ...
· The cost-effectiveness of methods for the prevention of prevalent infections that result in developmental disabilities, including vaccination and/or prophylaxis for such diseases as congenital rubella, Haemophilus inf~llenz~e Type b meningitis, measles, and malaria. · The etiology and prevention of adverse pregnancy outcomes, such as maternal morbidity and mortality, low birth weight, intrauterine growth restriction, and premature birth and birth defects with an emphasis not only on maternal and infant survival, but also on the prevention of developmental disabilities.
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From page 160... ...
So. Epilepsy in children with cerebral palsy.
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From page 161... ...
Prevalence and correlates of mental retardation among children in Karachi, Pakistan. American Journal of Epidemiology 1 47(3)
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From page 162... ...
A study of the prevalence of mental retardation in southern India. International Journal of Mental Health 10:28-36, 1981.
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From page 163... ...
Norton. Hearing loss prevalence and risk factors among Sierra Leonean children.
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From page 164... ...
Prevalence and correlates of mental retardation among children in Karachi, Pakistan. American Journal of Epidemiology Feb 1;147(3)
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From page 165... ...
96. ICMR Collaborating Centres and Central Coordinating Units, Multicentric study on genetic causes of mental retardation in India.
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From page 166... ...
American Journal of Clinical Nutrition, 35:127-134,1982.
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From page 167... ...
Nutritional supplementation, maternal education and cognitive development in infants at risk of malnutrition. American Journal of Clinical Nutrition 34: 807-813, 1981.
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From page 168... ...
Comiskey, et al. Correlations between intestinal parasitosis, physical growth and psychomotor development among infants and children from rural Nicaragua American Journal of Tropical Medical fIygiene Apr;58~4~:470~75, 1998.
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From page 169... ...
164. World Health Organization Haemophilus influenzae type b.
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From page 170... ...
Early mental and neurological sequelae after Japanese B encephalitis. Southeast Asian Journal of Tropical Medicine and Public Health Sep;25~3)
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From page 171... ...
Prenatal and postnatal risk factors for mental retardation among children in Bangladesh. American Journal of Epidemiology, (in press)
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From page 172... ...
The effect of malaria and malaria prevention in pregnancy on offspring birthweight, prematurity, and intrauterine growth retardation in rural Malawi. American Journal of Tropical Medical Hygiene 55~1~:33~1, 1996.
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From page 173... ...
infant survival, HIV infection, and feeding alternatives in less-developed countries. American Journal of Public Health 87~6~:92~931, 1997.
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From page 174... ...
Sep;16~3~:185-194, 1993. International Journal of Rehabilitative Research 255.
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From page 175... ...
American Journal of Public Health Jan;8 1~1~:]
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From page 176... ...
Health care economics: Impact on hearing loss prevetion in the developing world. Scandinavian Audiology (supplement)
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From page 178... ...
...... ~M:an~y: risk factors for epilepsy: :hav-e:.~been~ identified-: includ.ingl:bi:rth~l.~rauma~ I-:.: ..
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