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Indira Gandhi

National Open University MCFT-002


National Centre for Disability Studies
Mental Health and
Disorders

Block

4
PERSONS WITH DISABILITIES
UNIT 15
Orientation to Disabilities 7
UNIT 16
Persons with Sensory Impairments 20
UNIT 17
Persons with Mental Retardation 40
UNIT 18
Mental Illness and Psychosocial
Rehabilitation 62
UNIT 19
Persons with Locomotor Disability and
Multiple Disabilities 85
EXPERT COMMITTEE
Prof. V.N. Rajasekharan Pillai (Chairperson)
Vice Chancellor
IGNOU, New Delhi
Prof. Girishwar Misra Prof. Mathew Verghese Prof. Manju Mehta
Department of Psychology Head, Family Psychiatry Centre Department of Psychiatry
University of Delhi, New Delhi NIMHANS, Bangalore AIIMS, New Delhi

Prof. Shagufa Kapadia Prof. Reeta Sonawat Prof. Ahalya Raghuram


Head, Department of Human Head, Department of Human Department of Mental Health
Development and Family Studies Development, SNDT Women’s and Social Psychology,
The M.S. University of Baroda University, Mumbai NIMHANS, Bangalore
Vadodara

Dr. Rajesh Sagar Prof. Aruna Broota Prof. Anisha Shah


Associate Professor, Department of Psychology Department of Mental Health
Deptt. of Psychiatry, AIIMS & University of Delhi and Social Psychology,
Secretary, Central Mental Health New Delhi NIMHANS, Bangalore
Authority of India, Delhi

Prof. Rajni Dhingra Prof. T.B. Singh Prof. Sudha Chikkara


Head, Department of Human Head, Department of Clinical Department of Human
Development Psychology, IHBAS, New Delhi Development and Family Studies
Jammu University, Jammu CCS HAU, Hisar

Prof. Minhotti Phukan Mrs. Vandana Thappar Dr. Indu Kaura


Head, Deptt. of HDFS Deputy Director (Child Secretary, Indian Association for
Assam Agricultural University Development), NIPCCD Family Therapy, New Delhi
Assam New Delhi

Dr. Jayanti Dutta Ms. Reena Nath Dr. Rekha Sharma Sen
Associate Professor of HDCS, Practising Family Therapist Associate Professor
Lady Irwin College, New Delhi New Delhi (Child Development), SOCE
IGNOU, New Delhi
Prof. Vibha Joshi Prof. C.R.K. Murthy Mr. Sangmeshwar Rao
School of Education STRIDE Producer, EMPC, IGNOU
IGNOU, New Delhi IGNOU, New Delhi New Delhi

Prof. Neerja Chadha Dr. Amiteshwar Ratra


(Programme Coordinator) (Convenor & Programme
Professor of Child Development Coordinator)
School of Continuing Education Research Officer, NCDS
IGNOU, New Delhi IGNOU, New Delhi
Acknowledgment:
We acknowledge our thanks to Prof. Omprakash Mishra, Former PVC, IGNOU; Prof. C.G. Naidu, Former Director (I/c)
P&DD and Head, Nodal Unit; and Dr. Hemlata, Former Director (I/c), NCDS for facilitating the development of the
programme of study.

PROGRAMME COORDINATORS – M.Sc. (CFT) / PGDCFT


Dr. Amiteshwar Ratra Prof. Neerja Chadha
Research Officer Professor of Child Development
NCDS, IGNOU, New Delhi SOCE, IGNOU, New Delhi
COURSE COORDINATORS
Dr. Amiteshwar Ratra Prof. Neerja Chadha
Research Officer Professor of Child Development
NCDS, IGNOU, New Delhi SOCE, IGNOU, New Delhi

COURSE WRITERS
Unit 15 & 17 Dr. Amiteshwar Ratra, Research Officer, NCDS, IGNOU, New Delhi
Unit 16 Dr. S.K. Parsad, Dy. Director, NCDS, IGNOU, New Delhi
Unit 18 Prof. T.B. Singh, Dean, IHBAS, New Delhi
Unit 19 Ms Nupur Bhumbuck, Child Developement Expert, New Delhi
&
Dr. Amiteshwar Ratra, Research Officer, NCDS, IGNOU, New Delhi
BLOCK EDITORS
Prof. T.B. Singh
Prof. Neerja Chadha
Dean
Professor of Child Development
IHBAS
SOCE, IGNOU, New Delhi
New Delhi
Dr. Amiteshwar Ratra
Research Officer
NCDS, IGNOU, New Delhi

Acknowledgment :
We acknowledge our thanks to Ministry of Health and Family Welfare for providing inputs for
cover design.

September, 2010
 Indira Gandhi National Open University, 2010
ISBN:
All rights reserved. No part of this work may be reproduced in any form, by mimeograph or any other
means, without permission in writing from the Indira Gandhi National Open University, New Delhi.
Further information on Indira Gandhi National Open University courses may be obtained from the
University’s office at Maidan Garhi, New Delhi- 110 068 or the official website of IGNOU at
www.ignou.ac.in.
Printed and published on behalf of Indira Gandhi National Open University by Registrar, MPDD.
Laser Composed by: Rajshree Computers, V-166A, Bhagwati Vihar, (Near Sector-2, Dwarka),
Uttam Nagar, New Delhi-110059
Printed by:
BLOCK 4 PERSONS WITH DISABILITIES
The previous Block of this Course dealt with the various types of mental disorders,
such as cognitive disorders, mood disorders, neurotic disorders, personality
disorders etc. In this Block, “Persons with Disabilities” you will be oriented to
various types of disabilities. You will study disabilities like sensory impairments,
mental retardation, mental illness, locomotor disabilities and multiple disabilities.
This Block consists of five Units.
Unit 15 is on “Orientation to Disability”. The Unit defines disability and
differentiates disability from impairment and handicap. It explains the various
causes of disability like hereditary factors which include chromosomal anomalies,
defective genes etc. and environmental factors like poor nutrition, chronic disease,
radiations etc. It also explains that both heredity and environment interact to cause
disability. There are some important acts and legislations of Government of India
on disability. The Unit describes these acts in detail like RCI Act 1992, PWD
Act, 1995 and The National Trust Act, 1999. In the end of this Unit, we will
study how to create a disabled friendly society, wherein we would focus on the
various needs and problems of children with disabilities. We would also highlight
some important points to remember when dealing with persons with disabilities.
Unit 16 focusses on “Persons with Sensory Impairments”. As the name suggests,
the Unit acquaints you with the knowledge on sensory impairments like hearing
disability, visual disability and deaf blindness. The Unit begins with the concepts
and definition of sensory disability. Further, it explains various methods of
identification and assessment of sensory disability. The Unit describes the various
causes of sensory impairments. In the end of this Unit, various interventions for
sensory impairments are discussed; for example, sensory training, orientation and
mobility training for visually impaired persons.
Unit 17 is entitled “Persons with Mental Retardation”. The Unit begins with
the definitional aspects of mental retardation, and then proceeds to explaining the
various classifications in detail. The Unit further describes the various causes of
mental retardation. The identification and diagnosis of mental retardation has also
been focused upon. Children with mental retardation manifest some specific
physical, cognitive and behavioural characteristics; the Unit enumerates these
characteristics as well. The later part of the Unit deals with the prevention and
intervention for mental retardation. It includes genetic counselling, prenatal care
and postnatal care. Further, the Unit highlights the specific role of community
members like teachers and parents.
Unit 18 is on “Mental Illness and Psychosocial Rehabilitation”. The Unit
defines mental illness and its positive and negative symptoms. The disability arising
due to severe mental illness is known as psychiatric disability. The Unit explains
the clinical characteristics and key areas of psychiatric disability. Further, the Unit
explains the psychosocial rehabilitation of persons who are impaired, disabled or
handicapped by the mental disorder. It describes the aim, goals, values and
guiding principles of psychosocial rehabilitation. The Unit acquaints you with the
knowledge of historical perspectives of psychosocial rehabilitation. It explains the
present scenario and magnitude of the problem. Strategies of management in
psychosocial rehabilitation including pharmacotherapy and psychosocial
management are well explained in this Unit. The Unit also deals with the legal
aspects, advocacy and community participation. In the end of this Unit, the role
of the counsellor and family therapist is explained.
Unit 19 is entitled “Persons with Locomotor Disability and Multiple
Disabilities”. The Unit begins with the definition of locomotor disability and
various causes that may lead to locomotor disability. It also explains the other
conditions that lead to locomotor disability, for example, spinal cord injury, polio,
cerebral palsy, epilepsy, cerebrovascular accidents, arthritis, muscular dystrophy,
amputation, club foot and leprosy. The Unit further deals with the prevention of
locomotor disability, which includes primary level, secondary level and tertiary
level of preventions. Further, the Unit explains various types of problems faced
by the locomotor disabled. As you go through the Unit, you will be able to
understand the process of rehabilitation of locomotor disabled persons. It includes
assistive devices, orthodontics, prosthetics, walking aids etc. In the end of this
Unit, we study about multiple disabilities in which we learn about the causes,
examples and prevention of multiple disabilities.
UNIT 15 ORIENTATION TO
DISABILITY
Structure
15.1 Introduction
15.2 Definitions of Disability
15.3 Distinction between Disability, Impairment and Handicap
15.4 Causes of Disability
15.5 Legislations and Acts in India
15.6 How to Create a Disabled Friendly Society
15.6.1 Needs and Problems of Children with Disabilities
15.6.2 Points to Remember while Dealing with the Persons with Disabilities
15.6.3 Role of Society

15.7 Let Us Sum Up


15.8 Glossary
15.9 Answers to Check Your Progress Exercises
15.10 Unit End Questions
15.11 Further Readings and References

15.1 INTRODUCTION
Majority of us know of some one who has some kind of disability or, also, might
be ourselves suffering from some kind of impairment or disability. Disability is a
common term these days. Till recent past the words ‘disability’, ‘impairment’ and
‘handicap’ were used interchangeably. Most of the persons with disability till date
lead a segregated and secluded life due to our social misgivings and are deprived
of their rights to a larger extent. This Unit would differentiate among these three
terms. These terms have different meanings and are used in different contexts.
The estimated disabled population in the world as well as in India is quite high.
According to the Census of India, 2001 their number is 22 million. However,
according to the Disability Manual, 2005 brought out by the National Human
Rights Commission, Delhi the actual number of Indians with temporary and
permanent disability could be as high as 50 million. With the rising number of
persons with disabilities, it is pertinent for a counsellor and family therapist to
understand the needs, requirements and characteristics of persons with disabilities.
The information contained in this Unit will give a deeper understanding about the
persons with disabilities. In this Unit, we would have a general overview about
it and the other Units of this Block would discuss in detail about the specific
disability concerns.
Objectives
After studying this Unit, you will be able to:
 Differentiate the meaning of the terms disability, impairment and handicap; 7
Persons with Disabilities  List the factors that cause disability;
 Identify various types of disabilities;

 Understand the misconceptions associated with disability; and

 Contribute to the development of a disabled friendly society.

15.2 DEFINITIONS OF DISABILITY


The concept of disability differs from person to person and from survey to survey
depending on the base on which it is collected. In the simplest words, disability
refers to any limitation experienced by the disabled in comparison to the able
persons of similar age, sex and culture.

The Persons with Disabilities Act, 1995 defines “disability” in terms of blindness,
low vision, leprosy-cured, hearing impairment, locomotor disability, mental
retardation and mental illness. According to the Act, “person with disability”
means a person suffering from not less than forty percent of any disability as
certified by a medical authority.

The International Classification of Functioning (ICF), Disability and Health,


produced by the World Health Organisation (WHO), distinguishes between body
functions (physiological or psychological, for example, vision) and body structures
(anatomical parts, for example, the eye and related structures). Impairment in
bodily structure or function is defined as involving an anomaly, defect, loss or
other significant deviation from certain generally accepted population standards,
which may fluctuate over time. Activity is defined as the execution of a task or
fact or action by the bodily structure or function.

Medical Definition of Disability

Medically, disability is perceived as a medical clinical problem, thereby identifying


people with disabilities as ill, different from their non-disabled peers and unable
to take charge of their own lives. Medical definition does not take note of the
imperfections and deficiencies in the basic social structures and processes that fail
to accommodate the differences on account of disabilities. World Health
Organisation (WHO) defines the relationship between impairment, disability and
handicap. The term impairment refers to damage or loss related to organ level
functions or structures; disability refers to person-level limitation in physical and
psycho-cognitive activities; and handicap refers to social abilities or relation
between the individual and society. The ICF further states that the medical model
views disability as a problem of the person, directly caused by disease, trauma
or other health condition, which requires medical care provided in the form of
individual treatment by professionals.

Social Definition of Disability

The Disability Manual, (NHRC, 2005) focusses on the shift from individual
pathology to a social construct in accordance with the UN Standard Rules on the
Equalization of Opportunities for Persons with Disabilities, 1993. The Standard
Rules have defined disability from a perspective that emphasises social conditions
8 which disable a group of individuals by ignoring their needs of accessing opportunities
in a manner conducive to their circumstances (Disability Manual, 2005).
Human Rights Definition of Disability Orientation to Disability

The definition of disability should have human rights perspective. UN convention


on the Rights of Persons with Disabilities in 2009 promoted the human rights
perspective for persons with disabilities. Definition of disability takes into account
the social conditions which disable a group of individuals by ignoring their needs
of accessing opportunities in a manner different from others. Disability can be
defined as the disadvantage or restriction of activity caused by a society which
takes little or no account of people who have impairments and thus excludes them
from mainstream activities (Disability Manual, 2005).

Check Your Progress Exercise 1


Note: a) Read the following question carefully and answer in the space
provided below.
b) Check your answer with that provided at the end of this Unit.
1. Define disability according to the human rights perspective.
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................

15.3 DISTINCTION BETWEEN DISABILITY,


IMPAIRMENT AND HANDICAP
The World Health Organisation (WHO) has made distinctions between the
definitions of impairment, disability and handicap. The definitions given are as
follows:
An impairment is any loss or abnormality of psychological, physiological or
anatomical structure or function.
A disability is any restriction or lack (resulting from an impairment) of ability to
perform an activity in the manner or within the range considered normal for a
human being.
A handicap is a disadvantage for a given individual, resulting from impairment or
disability that limits or prevents the fulfillment of a role that is normal (depending
on age, sex, social and cultural factors) for that individual.
For example, suppose a person at the age of 15 years meets with an accident
and loses his right arm. This results in an impairment. Now, this person is not able
to write and use his right arm for functioning as he would use it earlier. This results
in a disability. This person when not able to perform his role as a student, for
instance, take notes in the class or write an examination, experiences a handicap.

9
Persons with Disabilities
Check Your Progress Exercise 2
Note: a) Read the following questions carefully and answer in the space
provided below.
b) Check your answers with those provided at the end of this Unit.
1. Fill in the blanks:
i) ........................ refers to organ level abnormality or dysfunction.
ii) ................................... refers to person level limitation in physical
and psycho-cognitive activities.
iii) ...................................................... is considered as a loss or limitation
of opportunities to take part in community life on an equal level with
others.

15.4 CAUSES OF DISABILITY


Disability could be a result of heredity, environmental factors and the interplay
between these two groups.
1. Heredity
Genetic components or heredity of an individual is one of the important causes
of disability. For instance, mental retardation is said to run in families and is
associated with hereditary endowments. Chromosomal anomalies, defective genes,
inheritance of fragile genetic components etc. lead to various disabilities among
humans. For example, 21st Trisomy. You have read about it in detail in Course
MCFT-001.
2. Environment
Environmental components play an important role in deformities which occur in
children. It starts from the moment of conception in the womb. Factors like poor
health status and nutritional intake of the mother as well as smoking, alcohol
consumption and exposure to radiation harm the foetus during pregnancy. Even
at the time of birth, the birth process may also lead to deformity in the infant.
Later jaundice, chronic health diseases, poor diet or nutrition intake (e.g. protein
energy malnutrition), accidents, etc. lead to disability among children.
3. Heredity and Environment Interplay
Both heredity and environment interact to cause disability. Heredity paves the
path and environment reinforces disability among the children.
Disability is caused by various factors which could be hereditary or non-hereditary.
World Health Organization (WHO) prepared a list of reasons of disability which
covers the following areas:
 Non-contagious somatic illnesses,
 Injuries/wounds,
 Malnutrition,
 Functional psychiatric disorders,
10
 Chronic alcoholism and drug abuse,
 Congenital diseases, and Orientation to Disability

 Contagious diseases.
In broad terms the causes of disability can be described as follows:

 Violation of human rights, torture, ill treatment or amputation,

 Natural disasters or earthquakes,

 Irreversible diseases,

 Old age,

 Environmental pollution,

 Cardiovascular disease,

 Neuromuscular diseases,

 Traffic accidents,

 Industrial accidents,

 Diseases like poliomyelitis,

 Wars,

 Mal-nutrition: Nutritional deficiency like lack of iodine leads to slow growth,


learning difficulties, intellectual disabilities, mental defects, deafness and
dumbness.
- VitaminAdeficiencyleads to blindness.
- Vitamin B Complex deficiency leads to beri-beri (inflammation or
degeneration of the nerves, digestive system and heart), pellagra (central
nervous system, gestro-intestinal disorders, skin inflammation) and
anaemia.
- Vitamin D deficiency leads to rickets (soft and deformed bones).
- Iron deficiencyleads to anaemia (impedes learning and activity).
- Calcium deficiency leads to osteoporosis (fragile bones).
 Chagas’ disease – Trypanosoma cruzi parasite is carried in the blood and
is spread by blood transfusions. This disease prevents the person from leading
a normal life and is also a cause of death,
 Down’s syndrome (Mongolism),

 Dwarfism (Achondroplasia),

 Insufficient care and cruelty towards children and women,

 Under development caused by lack of public hygiene, degradation of the


environment, poor food and housing, indigence, inadequate education and
health information, illiteracy,

 Hunger, 11
Persons with Disabilities  Lack of adequate health system,

 Use of certain pesticides, hormones, antibiotics or other additives,

 Dumping of toxic and dangerous products and wastes,

 Extreme poverty,

 Apartheid,

 Deliberately inflicted forms of punishment like mutilations, and

 Crime, for example, for begging children are amputated.

Check Your Progress Exercise 3


Note: a) Read the following question carefully and answer in the space
provided below.
b) Check your answer with that provided at the end of this Unit.
1. Which are the major areas covered under the list of reasons of disability
by WHO?
................................................................................................................
................................................................................................................
................................................................................................................

15.5 LEGISLATIONS AND ACTS IN INDIA


The year 1981 was declared as the International Year of Disabled Persons with
the theme as, “Full Participation and Equality”. On 3rd December, 1982, the
World Program Action Concern was adopted by United Nations to enhance full
participation of disabled persons in social life and national development. The
decade 1993-2002 was declared as Pacific Decade of Disabled Persons and in
1999, the decade was further extended to 2003-2012 as Asian Pacific Decade
of Disabled Persons and called Biwako Millennium Framework with the theme
“towards an inclusive, barrier-free and rights based society”.
Government of India like other countries agreed to implement the Biwako
Millennium Framework for Action towards an inclusive barrier-free and rights
based society for persons with disabilities in the Asia and the Pacific.
In the recent past, the welfare of the disabled has gained much importance.
Government of India has enacted various Acts and initiated various schemes and
measures for the welfare of the disabled. The Government of India has enacted
three major legislations for overall development and mainstreaming of persons
with disabilities, that are:
i) The RCI Act, 1992, which regulates the training policies and programmes in
the field of rehabilitation of persons with disabilities,
ii) The Persons with Disabilities (Equal Opportunities, Protection of Rights, and
Full Participation) Act, 1995, which aims to protect and promote the
educational, economic and social rights of persons with disabilities, and to
12 promote and ensure equality and full participation of persons with disabilities,
and
iii) The National Trust Act, 1999 which enables and empowers people with Orientation to Disability

autism, cerebral palsy, mental retardation and multiple disabilities.


All these legislations have come into force for overall growth of persons with
disabilities. The Persons with Disabilities Act, 1995 (PWD Act, 1995) is one of
the major Acts enacted for the welfare of the persons with disabilities. This Act
covers “Disability” in the following areas:
i) Blindness,
ii) Low vision,
iii) Leprosy-cured,
iv) Hearing impairment,
v) Locomotor disability,
vi) Mental retardation, and
vii) Mental illness.
These would be discussed in detail in the other Units of this Block. Recently,
Government of India signed the Convention on the Rights of Persons with Disabilities
and Optional Protocol for promotion of rights of the persons with disabilities.
According to this convention, we are now committed to promoting a Rights-
based society for the persons with disabilities, as matter of right of the disabled
people rather than the society doing any kind of favour or an act of sympathy for
them.
Check Your Progress Exercise 4
Note: a) Read the following question carefully and answer in the space
provided below.
b) Check your answer with that provided at the end of this Unit.
1. List the disabilities covered under the PWD Act.
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................

15.6 HOW TO CREATE A DISABLED FRIENDLY


SOCIETY
Now, let us discuss how we can create a disabled friendly society. A society
which is friendly and welcoming to the persons with disabilities needs to understand
their needs and problems before being able to be caring and inclusive.
15.6.1 Needs and Problems of Children with Disabilities
Needs and problems of children with disabilities are varied. The specific problems
of people with the disabilities would be discussed in the other Units of this Block.
Here, we would discuss in general the problems faced by children and people
13
with disabilities. These are:
Persons with Disabilities  Acceptance of one’s condition or problem: The persons with disability
and their family have to accept the disability or disabling condition. For
instance a hard of hearing child has to accept wearing hearing aid, child with
low vision has to wear thick spectacles, etc. and sit in the first row in the
class. Also, the other non-disabled children need to accept their classmate’s
condition.
 Acceptance by the society: People and children with disability like any
other person or child need to be accepted by others in the society. They
have a need of sense of belongingness, acceptance and love of their near and
dear ones. They need to be accepted as they are.
 Educational facilities: Children with disabilities should be provided education
and appropriate measures should be taken for their education.
 Vocational opportunities: Children and persons with disabilities should be
provided occupational and vocational rehabilitation and opportunities. As per
the abilities of the children with disabilities they should be given vocational
training.
 Assistive aids and assistive devices: The children with disabilities should
be given assistive aids, equipments and devices for facilitating them to meet
their learning, developmental and adjustment needs. Examples of such aids
are hearing aids for the hearing impaired, braille and talking books for the
blind, large print for low vision, etc.
 Barrier free environment: The physical environment of the children and
persons with disabilities should be barrier free. Provision of ramps in the
school and other public places is a step towards developing a barrier free
environment.
 Guidance, counselling and family therapy: Parents and/or caregivers of
children with disabilities need timely guidance, counselling and family therapy
to meet the developmental needs of their children. Also, need for counselling
and family therapy is felt by persons and children with disabilities. Various
social and emotional needs of these persons and their families may be met
with the help of the counsellor and family therapist. The other normal siblings
of the children with disabilities may also have certain problems and need to
be guided to face situations and their siblings. Counselling and family therapy
helps to channelise the parents and children/persons with disabilities to use
their emotional energy in useful productive ways as well as build resilience
and acceptance of each other. For example, a child with disability may be
jealous of his normal siblings and vice-versa.
Table 15.1: Myths related to the persons with disabilities
S.No. Myth Fact
1. Disabled child cannot attend With assistive aids and devices,
regular classroom. some modifications in the
infrastructural arrangement in the
school building and provision of
trained sensitised teachers
towards the needs of the
disabled, the disabled child can
attend regular classroom.
14
Orientation to Disability
2. The schools may or may not According to the provisions
admit children with disabilities. made under Indian legislation,
the schools do not have choice
to give admission or not to, the
differently abled but they have
to admit the child with disability.
3. Causes of disabilities are known. Causes of most of the
disabilities are known but not
for all the disabilities.
4. Treatment of disability is How to care and look after,
unknown. what remedial measures to be
undertaken are mostly known
about the different disabilities.
5. Disability and handicap Disability and handicap are
mean the same. two different terms. Disability
is caused by one’s inability to
do something while handicap is
the social restriction imposed on
the person.
6. Sympathy for the person with No, empathy for the person
disability is good. with disability is good.
7. They are not useful and Many disabled persons have
productive members of the become renowned persons in
society. They are not capable their professions. Many
of performing well in their disabled persons have invented
education or profession. things of immense use and
importance.
8. Disability is caused due to God’s It is a superstitious belief.
wrath on the person. Research shows that
undertaking preventive
measures can avoid many
disabilities.
9. Disabled cannot lead a Mildly disabled persons can
married life. lead a healthy married life.
10. People having severe epilepsy, Epilepsy and cerebral palsy
cerebral palsy can be cured cannot be cured with
with marriage. marriage.
11. Disabled persons like the They feel comfortable in the
company of other disabled company of people who
persons. accept them as they are. This
myth resulted from the fact that
in older days disabled persons
were kept separately.
12. Disabled people especially blind In fact, the lack of a sense
have sixth sense. makes other senses more
focused and sensitised.
13. Disabled people should be Overprotection of the
protected against failure. disabled people should be
avoided. They should be given
opportunity of both failure and
success like other normal human
beings. 15
Persons with Disabilities 15.6.2 Points to Remember while Dealing with the
Persons with Disabilities
One should remember the following points while dealing with the person with
disability:
 Do not discriminate against persons with disabilities. They are human beings
like anyone else with different abilities and needs.
 To remove misconceptions about transmission or spread of disability, general
public should be educated and sensitised towards the concept of disability.
 It is necessary for the masses to have acceptance of the disabled which will
help to eradicate handicappedness among the disabled so that social change
in favour of the person with disabilities is brought about.
 Indigenous material, that is material available in the local area should be used
to lessen the effect of disability.
 Do not stigmatise and sympathise with the disabled. Rather, sensitise,
empathise, make aware, spread information and educate the common person
towards the needs and abilities of the persons with disabilities.
 The requisite additions and modifications should be made in the public utility
services, like buildings, transport system, etc. to make them user friendly for
the disabled.
 To help the persons with disabilities develop a well organised social support
system of family, neighbourhood and the workplace.
 Services leading to treatment and rehabilitation of the disabled are a must
and their availability and use should be promoted.
 Innovations leading to development of services and materials for the disabled
should be encouraged.
15.6.3 Role of Society
Society has an important role to play in the development of its inhabitants. Child
is born in the society and dies in the society. It is the society that decides what
is “average”, “normal”, “deviation”, “exceptional” and “different”. The social
norms of the society regulate the overall development of the individuals. So, it
becomes the duty of the society to provide optimum environment to the differently
abled. The boundaries of the medical and social disability need not become a
handicap for the person if the society so desires.
Parents, teachers and caregivers of the persons with disabilities need to keep an
appropriate balance between over protection to over stimulation. Care needs to
be taken that enough opportunities are provided to the differently abled child to
develop independence and self esteem. Social participation of the differently
abled gets slackened and stunted in many activities due to the cultural and social
handicap these individuals face. People think they need to be sympathised with
and looked down upon always, but, instead they should be provided empathy of
the society and opportunities to grow into an independent person. Self-dependence
would lead to self-decisions which would enhance their self-esteem and help them
to develop a good self-concept. This helps the differently abled to become
16 productive and useful members of the society.
Orientation to Disability
Check Your Progress Exercise 5
Note: a) Read the following question carefully and answer in the space
provided below.
b) Check your answer with that provided at the end of this Unit.
1. State True or False.
i) Causes of disabilities are known. ................................
ii) Sympathy for the persons with .................................
disability is good.
iii) Only blind persons have sixth sense. .................................
iv) Epilepsy and cerebral palsy cannot .................................
be cured with marriage.

15.7 LET US SUM UP


The census 2001 shows that there are about 21 million persons (2.1 per cent of
the population) in the country having one or another form of disability. Under
these circumstances the Government of India has enacted three major legislations
for overall development and mainstreaming of persons with disabilities, that are,
(i) the RCI Act (1992), which regulates the training policies and programmes in
the field of rehabilitation of persons with disabilities, (ii) the Persons with Disabilities
Act (1995), which aims to safeguard the rights and ensure provision of requisite
facilities to persons with disabilities and (iii) the National Trust Act (1999) to
enable and empower people with autism, cerebral palsy, mental retardation and
multiple disabilities. One needs to understand the causes of disability, needs and
problems of children with disabilities to facilitate their inclusion in the mainstream
society in all aspects. A society cannot declare itself modern and equitable, unless
it makes sincere efforts to achieve equality in extending opportunities for all its less
privileged citizens including the persons with disabilities.

15.8 GLOSSARY
Disability : Restriction or lack of ability to perform an activity in
the manner considered normal among human beings.
FAS : Foetal Alcohol Syndrome.
ICF : International Classification of Functioning.
Impairment : Any loss or abnormality of psychological, physiological
or anatomical structure or function.
WHO : World Health Organisation.

15.9 ANSWERS TO CHECK YOUR PROGRESS


EXERCISES
Check Your Progress Exercise 1
1. According to human rights perspective, disability can be defined as
disadvantage or restriction of activity caused by a society which takes little
or no account of people who have impairments and thus excludes them from
mainstream activities. 17
Persons with Disabilities Check Your Progress Exercise 2

1. i) impairment

ii) disability

iii) handicap

Check Your Progress Exercise 3

1) Following are the major areas covered under the list of reaons of disability
by WHO:

i) Non-contagious somatic illnesses,

ii) Injuries/wounds,

iii) Malnutrition,

iv) Functional psychiatric disorders,

v) Chronic alcoholism and drug abuse,

vi) Congenital diseases, and

vii) Contagious diseases.

Check Your Progress Exercise 4

1. Following are the disabilities covered under PWD Act:

i) Blindness,

ii) Low vision,

iii) Leprosy-cured,

iv) Hearing impairment,

v) Locomotor disability,

vi) Mental retardation, and

vii) Mental illness

Check Your Progress Exercise 5

1. i) False

ii) False

iii) False

iv) True
18
Orientation to Disability
15.10 UNIT END QUESTIONS
1. How will you differentiate between disability and handicap? Explain with
examples.
2. Describe the legislations and acts related to disability.
3. How will you create a disabled friendly society? Illustrate with the help of
examples.

15.11 FURTHER READINGS AND REFERENCES


Disability. http://en.wikipedia.org/wiki/Disabled. Dated: 2/3/2010.
Disability Manual, 2005. National Human Rights Commission.
Hallahan, P. & Kauffman, M. (1991). Exceptional children: Introduction to
special education. Fifth Edition. Englewood Cliffs: Prentice-Hall International
Inc.
Husain, M.G. (1984). Problems and potentials of the handicapped. New Delhi:
Atlantic Publishers and Distributors.
Kirk, A. (1997). Educating exceptional children. New Delhi: Oxford & IBH
Publishing Co.
Persons with Disabilties Act, 1995, www.http://socialwelfare.delhigovt.nic.in/
disabilityact.htm
Regional Mechanism on Disability. http://www.dpiap.org/Regional%20
Mechanism%20on%20 Disability%20 Movement.html. Dated: 2/3/2010.
The Asian and Pacific Decade of disabled Persons, 2003-2012: “Towards an
Inclusive, Barrier-Free and Rights based Society”. Action guideline: The Biwako
Millennium framework. http://www.apcdproject.org/country profile/india/india -
plan.html Dated: 29/2/2010.
Uddin, H. (1995). Normal and handicapped children: A comparative
approach. New Delhi: Ashish Publishing House.

19
Persons with Disabilities
UNIT 16 PERSONS WITH SENSORY
IMPAIRMENTS
Structure
16.1 Introduction
16.2 Concepts and Definitions
16.2.1 Hearing Impairment
16.2.2 Visual Impairment
16.2.3 Deaf Blindness

16.3 Identification and Assessment


16.3.1 Hearing Impairment
16.3.2 Visual Impairment
16.3.3 Deaf Blindness

16.4 Causes and Types


16.4.1 Hearing Impairment
16.4.2 Visual Impairment
16.4.3 Deaf Blindness

16.5 Intervention
16.5.1 Hearing Impairment
16.5.2 Visual Impairment
16.5.3 Deaf Blindness

16.6 Let Us Sum Up

16.7 Glossary

16.8 Answers to Check Your Progress Exercises

16.9 Unit End Questions

16.10 Further Readings and References

16.1 INTRODUCTION
This Unit will provide you a broad overview of the concept and definition
of sensory impairment and its rehabilitation and mainstreaming needs. The
concept, identification and assessment, support services and various other
related aspects of sensory disability have been explained in very objective
terms. Besides above, this Unit deals with the identification based on common
characteristics, and aids and appliances meant for the persons with sensory
impairment. Here the types of sensory impairments such as hearing
impairment, visual impairment including blindness and low vision and multi-
sensory impairment as deaf blindness have been discussed in detail. The
Unit is designed to cover various dimensions with a view to enable you to
help and deal with the persons having sensory disability. These include
management of the different aspects of rehabilitation.
20
Objectives Persons with Sensory
Impairments

After studying this Unit, you will be able to:

 Explain the concept and meaning of sensory impairment;

 Identify and assess the children and persons with sensory impairments; and

 Plan specific intervention with regard to the children and persons with sensory
impairments.

16.2 CONCEPTS AND DEFINITIONS


Sensory impairment refers to difficulty either in seeing or hearing. There are
different levels of difficulty; for instance, some people may not be able to
hear at all while others will be able to hear partly and might use hearing aids.
In the same way, a person could be totally blind or able to see partly. The
following Section will help us in developing a clear understanding about the different
types of sensory impairments, which include the following:

16.2.1 Hearing Impairment


The importance of hearing is known to everybody. You cannot imagine the agony
faced by a persons, who has a problem in hearing or hearing impairment. Some
important concepts related to hearing impairment are discussed below:

Hearing : Hearing is a process of detection, discrimination,


recognition and comprehension of sounds.

Hearing impairment : Hearing impairment may be defined as any deviation


or change for the worse in either auditory structure
or auditory function. This may involve any defect in
the hearing process due to hereditary or
environmental factors. Owing to this impairment the
child cannot use her or his hearing for ordinary
purpose.

Hearing disability : Hearing disability is defined as the auditory problem


experienced and complained by the individual. When
the impairment reduces the child’s functional potential
and restricts her or his level of performance, it
becomes a hearing disability.

The Persons with Disabilities Act, 1995, recognises


having impairment as a disabilitiy, defining it as a
loss of sixty decibels or more in the better ear in the

conversational range of frequencies.

Hearing handicap : Hearing handicap is the disadvantage for an individual


resulting from the impairment or disability, which
limits or prevents the fulfillment of a normal role 21
depending on age, sex, and social and cultural
Persons with Disabilities factors for the individual. The restriction imposed
upon, or acquired by the individual affects the
efficiency of her or his day-to-day life. For example:
1. A defect in the eardrum is impairment. It distorts the
process of sound vibration and restricts the normal
process of transfer of the message to the middle
ear.
2. This distortion creates a disability in hearing as the
normal process of hearing sounds cannot be
performed.
3. The result is the loss of quality of life.

16.2.2 Visual Impairment


Vision is the most important sense required to observe and learn from what is
happening in one’s environment. Any type of impairment in vision not only creates
problems in the learning process rather it disturbs whole development of the
individual. Visual disability ultimately hampers the development of the child or
person, especially her or his learning.
Broadly, visual impairment can be divided into two types. These are:
1. Low vision: Low vision means markedly reduced functional vision in the
individual. Low vision may demand large print materials and magnifiers for
reading. Recent technological advancement has facilitated better learning
opportunities for low vision children. A person with low vision is one who
has impairment of visual functioning even after treatment; for example an
operation and/or standard refractive correction with glasses or lenses. The
Persons with Disabilities Act, 1995, recognises low vision as a category of
disability and defines it as follows:
“Person with low vision” means a person with impairment of visual
functioning even after treatment of standard refraction.
2. Blindness: “Blindness” refers to a condition where a person suffers from
total absence of sight or extremely limited field of vision or visual acuity not
exceeding 6/600 or 20/200 in the better eye even with corrective lenses or
limitations of the field of vision subtending an angle of 20 degree or worse.

16.2.3 Deaf Blindness


Deaf blindness is a dual sensory loss involving visual as well as auditory sense.
According to the U.S. Federal law governing special education (Individuals with
Disabilities Education Act – IDEA), the term “children with deaf blindness” means
children and youth having auditory and visual impairments, the combination of
which creates such severe communication and other developmental and learning
needs that they cannot be appropriately educated without special education and
related services, beyond those that would be provided solely for children with
hearing impairments, visual impairments, or severe disabilities, to address their
educational needs due to these concurrent disabilities. (PL101 – 476, 20 USC,
22 Chapter 33, Section 1422 [2])
Check Your Progress Exercise 1 Persons with Sensory
Impairments

Note: a) Read the following questions carefully and answer in the space
provided below.
b) Check your answers with those provided at the end of this Unit.
1. Fill in the blanks:
i) Sensory impairment refers to difficulty either in ............................... or
hearing.
ii) ......................... is a process of detection, discrimination, recognition
and comprehension of sounds.
iii) Persons with low vision mean a person with impairment of
............................... even after treatment of standard refraction.
iv) Deaf blindness is a ............................... sensory loss.

16.3 IDENTIFICATION AND ASSESSMENT


There are different methods for identification and assessment of all types of
sensory impairments. The identification can be done through common features or
symptoms and through formal clinical methods.

16.3.1 Hearing Impairment


The child with hearing impairment can be identified with the help of the following
methods:
During childhood it can be identified through the following symptoms or features:
 History of high risk factors,
 Absence of normal response to various sounds,
 Language development not seen even after one to two years of age,
 Attention on the lips of the speaker,
 Liquid discharge from ears, and
 Constant itch in the child’s ear.
Hearing impairment at classroom level can be identified through:
 Lack of linguistic skills, normal for one’s age,
 Difficulty in comprehension,
 Specific problem in reading and speaking,
 Slow mastering of language skills, and
 Asking for repetition frequently.
Assessment: Assessment of hearing impairment can be done to know the degree
and type of hearing loss. This can be done in two ways. It is illustrated through
following Fig. 16.1.
23
Persons with Disabilities
Observation by parents
Assessment  Informal

Formal Child’s behaviour

 Observation by teachers
 Audiologist
 Special Educator
 Psychologist
 Speech Therapist
 Social Worker

Fig 16.1 : Assessment of hearing impairment

The child showing one or more than one of the above mentioned signs and
symptoms should be referred to an audiologist. The audiologist assesses the
hearing loss using various audiological equipment like pure tone audiometer,
speech audiometer, play audiometer, sound field audiometer, impedance
audiometer, Brain Evoked Response Audiometry (BERA), etc. It is now
possible to assess degree and type of hearing loss at an early age of the child.
Screening Audiological Tests for Infants and Children
There are a number of screening audiological tests depending upon the age
of children. Let us discuss some of these tests:
1. Birth to Six Months
Infants with congenital or neonatal hearing loss can be identified using
objective physiological tests such as the Auditory Brainstem Response (ABR)
evaluations, or the Oto Acoustic Emission (OAE) before 3 months of age,
and an intervention programme started soon thereafter. Both these tests are
accurate, non-invasive and do not require any observable response from the
infant. For the purpose of screening, both the methods are extremely effective.
i) Auditory Brainstem Response (ABR): In order to process sounds,
electrical impulses are transmitted through nerves from our ears to the
brainstem at the base of the brain. An auditory brainstem response
(ABR) is a physiological measure of the brainstem’s response to sound.
It tests the integrity of the hearing system from the ear to the brainstem.
The test is performed by fixing four to five electrodes on the infant’s
head, after which a variety of sounds is presented to the infant through
earphones. As the hearing nerve fires, the sound stimulus travels up to
the brain. This electrical activity generated by the nerve can be recorded
by the electrodes and is represented as waveforms on a computer screen.
The audiologist can then present different loudness levels of each sound
and determine the softest levels at which the infant can hear. For infant
screening purposes, only one sound is used to test the hearing, commonly
referred to as a “click”. The click is a grouping of several sounds to test
a wider area of the hearing organ at one time. The click is typically
presented at a loud level and a soft one. If a healthy response is recorded,
then the infant has “passed” the hearing screen.
ii) Automated Auditory Brainstem Response (AABR): The automated
auditory brainstem response (AABR) is another objective means of evaluating
24 hearing. It is mainly used in many newborn-screening programmes. The
instrument is automated and provides a pass-fail report; no test interpretation Persons with Sensory
Impairments
by an audiologist is required.
iii) Otoacoustic Emission Test (OAE): The otoacoustic emission test (OAE)
measures an acoustic response that is produced by the inner ear (cochlea),
in response to a sound stimulus. The test is performed by placing a small
probe that contains a microphone and speaker into the infant’s ear. As the
infant rests quietly, sounds are generated in the probe and responses that
come back from the cochlea are recorded. Once the cochlea processes the
sound, neural impulses are sent to the brainstem. In addition, there is a
second and separate sound that does not travel up the nerve, but comes
back out into the infant’s ear canal. This “byproduct” is the otoacoustic
emission. The emission is then recorded with the microphone probe and
represented pictorially on a computer screen. The audiologist can determine
which sounds yielded a response or emission and the strength of those
responses. If there is an emission present for those sounds that are critical
to speech comprehension, then the infant has “passed” the hearing screen.
Both ABR and OAE tests have advantages and disadvantages when used
for screening. The OAE is easy and cost effective. However, the false-
positive rate (that is, an infant fails a hearing test but actually has normal
hearing) may be higher for an OAE than for an ABR. The two tests, however,
rely on different mechanisms of hearing for the screening. For in-depth testing
and a complete hearing evaluation of infants, these tests work best together
as a complement to each other.
2. Six Months to Two Years
Conditioned Oriented Response (COR) or Visual Reinforcement
Audiometry (VRA): Children as young as six to 12 months of age can be
screened using conditioned oriented responses or visual reinforcement
audiometry. These are the behavioural tests measuring responses of the child
to speech and frequency-specific stimuli presented through speakers. Both
the techniques condition the child to associate speech or frequency-specific
sound with a reinforcement stimulus, such as a lighted toy. However, these
tests do not give ear-specific results.
3. Two Years to Four Years
Play audiometry is a behavioural test aimed at measuring the auditory
thresholds in response to speech and frequency-specific stimuli presented
through earphones or bone vibrator. The child is conditioned to put a peg
in a pegboard or drop a block in a box when stimulus tone is heard. It gives
ear-specific results and assesses auditory perception of the child. However,
attention span of the child may limit the amount of information obtained.
4. Four Years to Adolescence
Conventional Pure Tone Audiometry is a behavioural test measuring
auditory thresholds in response to speech and frequency-specific stimuli
presented through earphones or bone vibrator. The child is instructed to raise
her or his hand when stimulus is heard. It gives ear-specific results and
depends on the level of understanding and cooperation of the child.

25
Persons with Disabilities 16.3.2 Visual Impairment
When prevention of disability is not possible, cure becomes the objective. When
cure is not possible, rehabilitation becomes the goal. Identification and assessment
help a great deal in facilitating rehabilitation of the blind and those with low vision.
The assessment of disability and identification of children or persons with visual
disability may be based on the common features, informal methods such as direct
observation and formal procedures with the help of some assessment tools. The
details in this respect are given below:
Common features: Visual impairment may be identified with the help of common
features as mentioned below:
Blindness
 Child tilts her or his head to locate the light source,
 Pain and irritation in the eyes,
 Bumps into objects in the environment,
 Unable to write from the blackboard, takes help from peers to copy
from the blackboard,
 Poor performance in the class,
 Unable to read in poor lighting conditions,
 Unable to see during night,
 Depends too much on oral information,
 Rubs eyes excessively,
 Watery eyes,
 Eyelids are often red,
 Holds objects and the book too close to eyes,
 Squints or blinks when looking at something,
 Blinks more frequently, and
 Regular headaches.
Low Vision
 Confident movement in school environment,
 Visual orientation to the new stimuli,
 Light gazing,
 Avoidance response to shadows,
 Interested in visual games,
 Avoidance of large obstacles,
 Unusual head tilt,
26  Flickering,
 Distracted by movement in the environment, Persons with Sensory
Impairments
 Startled response to suddenly approaching objects,
 The child experiences difficulty in reading small prints,
 The child experiences difficulty in identifying small details in
pictures or illustrations,
 The child frequently complains of dizziness after reading a passage
or completion of assignments involving vision, and
 The child frequently complains of headache, infection in eye; the
child uses one eye more than the other.
Informal Methods of Assessment
There are some informal methods to identify visual impairment. These are simple
methods and activities that parents and teachers can use in the classroom for
assessing visual problems of the child, if any.
Direct Observation
 Light perception of difference between sunlight and dim light,
 Light perception of difference between good light and poor light in a
class,
 Tracking of light,
 Detecting hand movement,
 Distance of detecting hand movement,
 Finger counting: Fingers raised one at a time,
 Finger counting: Fingers spread apart,
 Finger counting (General): Fingers closed together,
 Finger counting inside the classroom with good lighting condition,
 Finger counting inside the classroom with poor lighting condition,
 Visual background,
 Colour detection,
 Visual closure,
 Form constancy,
 Eye-hand coordination,
 Eye-foot coordination,
 Print size preference without magnifiers,
 Print size preference with magnifiers,
 Time taken to read a passage in mother tongue or English,
 Ability to write, and
 Writing speed.
27
Persons with Disabilities Formal Methods of Assessment

The assessment of visual problems requires teamwork of educational, medical


and other personnel such as volunteers and health workers. The teamwork consists
of vision screening of all children, continuous classroom observation for behavioural
and physical symptoms, and extending referral services for identified children for
comprehensive eye examinations. An adequate programme of identification requires
carrying out of each step in a carefully planned systematic manner.

Some children may be handicapped due to the restriction of the field of vision.
The field of vision is the entire area which can be seen while the eye remains
fixed upon one point in straight line. When the widest angle of the central field is
restricted to 20 degrees or less in the better eye with correction, the person is
considered legally blind, even though she or he is usually able to read ink print
materials.

Assessment Tools

These are commonly used tests to measure the extent of visual functioning and are
discussed in brief in this sub section.

Snellen test and visual field tests: These tests are used to measure visual
acuity and visual field.

Muscles Balance Tests: For testing muscle balance, special instruments are
used. The most common tests are:

 Maddox Rod Test: This test is used to determine the postural position of
the eyes when fusion is disrupted. This test yields excellent measurement of
heterophoria and can also be used to detect hetrophoria. The procedure
calls for the presentation of a different image to each eye at the same time.

 Allied Muscle Balance Test: This test consists of a procedure in which


the child wears specialised lenses while using a projector to place a red dot
within a rectangle projected on a screen. This test may be difficult to teach
to some children, and it requires fine motor control and eye-hand coordination.

 Tests for Distant Vision: The tests for distant vision will detect the child
with hyperopia or far-sightedness. The hyperopic child usually sees quite
well at a distance but must accommodate for near-vision task.

 Plus Lens Test: It is a more adequate test to detect hyperopia. The child’s
vision is checked on the Snellen chart or on one of the binocular instruments
while he is wearing plus lenses mounted in a small, inexpensive frame. If the
child can see the 20 feet line at 20 feet from the chart with both eyes while
wearing these lenses, she or he should be referred.

 Near Vision Testing: Near visual acuity should be determined for children
with low vision. Near vision information is of special importance for children
with pathological defects where only distance visual acuity may be inadequate.
Near vision is determined with one of several reading cards, which have
either symbols, numerals or letters printed on them. The reading distance for
low vision children and illumination should be recorded.
28
16.3.3 Deaf Blindness Persons with Sensory
Impairments

All the methods applied for identification of hearing and visual disability that we
have discussed earlier may be used in combination for identification of deaf
blindness in the individual.

Check Your Progress Exercise 2


Note: a) Read the following questions carefully and answer in the space
provided below.
b) Check your answers with those provided at the end of this Unit.
1. List the various common features based on which the persons having sensory
impairment can be identified.

.................................................................................................................

.................................................................................................................

.................................................................................................................

2. What are the assessment tools used to measure visual functioning?

.................................................................................................................

.................................................................................................................

.................................................................................................................

16.4 CAUSES AND TYPES


There are many causes which directly or indirectly contribute to the development
of sensory disability. Some causes are dominating contributors and some are
supportive in the development. Let us now take a look at the causes and types
of hearing loss, visual impairment and deaf blindness.
16.4.1 Hearing Impairment
The ear is the sense organ of hearing. It is mainly divided into three parts:
a) Outer ear,
b) Middle ear, and
c) Inner ear.

The sound waves from the environment including speech enter the outer ear,
strike on the eardrum, and make the tiny three bones in the middle ear
vibrate. This results in the transfer of mechanical energy in the middle ear
and then into electrical energy in the inner ear. Frequency and intensity analysis
of sounds takes place in the inner ear. The electrical energy from the inner ear
is carried to hearing area in the brain through auditory nerve and other complex
auditory pathways for processing and interpretation of the meaning of the sounds.
The hearing loss can occur due to damage at any stage or in different parts of
ear. The causes of hearing disability can occur at any time during the developmental
period that is before birth, during birth or after birth. The causes before birth may 29
Persons with Disabilities concern family history of childhood deafness, consanguineous marriages, illness
during pregnancy, history of mother suffering from rubella during pregnancy and
poor physical condition of the mother. The possible causes during birth are premature
delivery, lack of oxygen during birth, absence of birth cry and low birth weight.
The causes after birth are deformities of ear, nose, face and throat; infectious
diseases (mumps, measles, meningitis, viral fever etc); injury to ear, exposure to
loud sound and neglected ear discharge. Children with the above factors may be
considered as high-risk children and their hearing assessment should be done as
early as possible.
Higher the level of hearing sensitivity, greater the severity of hearing loss. Hearing
loss may be mild, moderate, moderately severe, severe or profound:
 Mild hearing loss (26 to 40 dB HL): A child with mild hearing loss will
have trouble hearing and understanding soft speech in a noisy background.
 Moderate hearing loss (41 to 55 dB HL): A child with moderate hearing
loss will have difficulty in hearing conversational speech.
 Moderately severe hearing loss (56 to 70 dB HL): A child with
moderately severe hearing loss will have difficulty in hearing conversational
speech even at close distances.
 Severe hearing loss (71 to 90 dB HL): A child with severe hearing loss
may only hear loud environmental sounds.
 Profound hearing loss (91 dB HL and above): A child with profound
hearing loss may only hear very loud environmental sounds.
The types of hearing loss are as follows:
i) Conductive hearing loss: Hearing loss due to any problem in the outer
ear and/or middle ear can lead to conductive hearing loss.
ii) Sensory neural hearing loss: Hearing loss due to any problem in the inner
ear and/or auditory nerve is termed as sensoy-neural hearing loss.
iii) Mixed hearing loss: Hearing loss due to any problem in the outer and /
or middle ear including inner ear is termed as mixed hearing loss.
iv) Central hearing loss: The hearing loss due to defects in central auditory
processing is termed as central hearing loss. The child can hear the sound
but has problem in understanding and interpreting the speech and language.
v) Functional hearing loss: This is hearing loss when there is no anatomical
and physiological abnormality in the auditory system but the child has problem
in hearing due to malingering or psychological problems.
16.4.2 Visual Impairment
VISION 2020 has identified many causes of avoidable blindness, among which
five conditions have been identified for immediate priorities on the basis of the
burden of blindness they represent and the feasibility and affordability of interventions
to prevent and treat them. These are cataract, trachoma, onchocerciasis, childhood
blindness, and refractive errors and low vision. Other disorders, such as glaucoma
and diabetic retinopathy, at present do not meet all these criteria, but are likely
30 in the future. Let us discuss some of the common causative conditions:
 Cataract: It refers to a clouding of the crystalline lens of the eye and stands Persons with Sensory
Impairments
out as the first priority amongst the major causes of blindness. Today, an
estimated 20 million people are blind from this condition. Cataracts are not
generally amenable to prevention but currently available surgery can restore
near normal vision in a large proportion of those who suffer from this condition.
 Trachoma: Trachoma remains the most common preventable cause of
blindness in the world. Trachoma is common in areas of the world that
are socio-economically deprived of basic needs in housing, health, water
and sanitation including India.
 Childhood blindness: Childhood blindness is caused mainly by vitamin
A deficiency, measles, conjunctivitis in the newborn, congenital cataract
and retinopathy of prematurity (ROP).
Other causes of childhood blindness that are congenital, or genetically
determined, do not generally lend themselves easily to preventive
strategies at present.
Childhood blindness is considered as a priority area, because of the
number of years of blindness that ensues. Its developmental implications
are tremendous.
16.4.3 Deaf Blindness
To know more about deaf blindness let us understand the four groupings of
individuals who are deafblind.
1. Congenitally deafblind: Individuals who are born with vision and
hearing losses.
2. Congenitally deaf, adventitiously blind: Individuals who are born with
deafness and later acquire blindness.
3. Congenitally blind, adventitiously deaf: Individuals who are born with
blindness and later acquire deafness.
4. Adventitiously deafblind or acquired deafblind: Individuals who are
born with hearing and vision senses but later lose both the senses in
varying degrees and at different times.

Check Your Progress Exercise 3


Note: a) Read the following questions carefully and answer in the space
provided below.
b) Check your answers with those provided at the end of this Unit.
1. List the types of hearing loss.

.................................................................................................................

.................................................................................................................

.................................................................................................................

.................................................................................................................
------------------------------------------------------------------------------------------ 31
Persons with Disabilities ---------------------------------------------------------------------------------------------
2. What are the major causes of avoidable blindness identified by VISION
2020?

.................................................................................................................

.................................................................................................................

.................................................................................................................

.................................................................................................................

16.5 INTERVENTION
Intervention is a major and important aspect of rehabilitation process. It is a team
approach, in which the role of parents, family members and community people
are equally important. Let us now take a focussed look at intervention in the case
of sensory impairment.

16.5.1 Hearing Impairment


Approximately 1 of every 1,000 children is born deaf. Many more are born with
less severe degrees of hearing impairment, while others develop hearing impairment
during childhood. Reduced hearing acuity during infancy and early childhood
interferes with the development of speech and verbal language skills. Although
less well documented, significantly reduced auditory input also adversely affects
the developing auditory nervous system and can have harmful effects on social,
emotional, cognitive and academic development, as well as on a person’s vocational,
and economic potential. Moreover, delayed identification and management of
severe to profound hearing impairment may impede the child’s ability to adapt to
life in a hearing world or in the deaf community.
The family members who have just come to know that their child has a hearing
loss typically have no prior experience or information about what this means for
their child and family. Since more than 90 per cent of the parents with a child who
is deaf or hard of hearing are themselves able to hear, the news often comes as
a complete surprise. Although parents react to the identification of their child’s
hearing loss in many different ways, they often need support as they adjust to this
new and unexpected information. Parents want information about their child’s
hearing abilities, how to communicate clearly, and how they can enhance their
child’s development. Early intervention services provide families with support and
information that promote the family’s abilities to support their child’s growth and
development, keeping in mind the special needs of the child. The intervention in
the case of hearing disability consists of language and speech therapy, behaviour
therapy, family counselling and fitting of hearing aid and ear mould.
The most important period for language and speech development is generally
regarded as the first 3 years of life and, although there are several methods of
identifying hearing impairment during the first year, the average age of identification
in the United States remains close to 3 years and even higher in India. Lesser
degrees of hearing loss may go undetected even longer. The result is that for many
hearing-impaired infants and young children, much of the crucial period for language
and speech learning is lost. There is general agreement that hearing impairment
should be recognised as early in life as possible, so that the remediation process
32
can take full advantage of the plasticity of the developing sensory systems and so Persons with Sensory
Impairments
that the child can enjoy normal social development.
During the past 30 years, infant hearing screening has been attempted with a
number of different test methods, including cardiac response audiometry, respiration
audiometry, alteration of sucking patterns, movement or startle in response to
acoustic stimuli, auditory brain stem response (ABR) audiometry has been the
method of choice. More recently, attention has turned to the measurement of
evoked otoacoustic emissions (EOAE), which show promise as a fast, inexpensive,
non-invasive test of cochlear function.
Each method is effective in its own way, but technical or interpretative limitations
have impeded its widespread application. Moreover, these approaches vary in
their sensitivity, specificity and predictive value in identifying hearing impairment.

16.5.2 Visual Impairment


Following are some of the interventions for visually impaired persons.
1. Sensory Training
Many people believe that persons with visual impairment have God given abilities
in using their senses but it is not true. The abilities of the senses will not develop
unless they are specifically trained. As sighted persons tend to rely mostly on the
vision, the other senses are not used to the optimum level whereas a visually
impaired person is compelled to use other senses. Therefore, proper training in
the use of the remaining senses becomes vital. The ability to use the senses
enhances the orientation and mobility skills of the child too as concepts like
landmark, clue, etc., that we use in the mobility training help the child to understand
the environment better. Therefore, systematic development of the abilities to use
the senses becomes an integral part of the training to the visually impaired child.
2. Orientation and Mobility
There are visually disabled individuals who are extremely capable of moving
independently without any physical assistance in a known environment. Such
individuals have a complete control over things in the environment and their
judgement about the distance, direction, etc. of these objects and the relation to
self may be remarkable. Visually disabled children are trained by teachers and
mobility instructors to have safe, secure and graceful mobility skills. Persons with
these abilities are able to move unassisted in known environment. Though this is
commendable, the visually disabled individual must be encouraged to use a mobility
device as it provides independence even in an unknown environment. The skills
also differ between visually disabled person from birth and the one who has
acquired blindness later in life.
To improve the mobility, visually impaired persons use the following:
 Sighted guide travel: We also come across visually disabled individuals
who prefer to travel with the help of a sighted companion. Specific sighted
guide techniques are necessary both for the guide and for the visually disabled
individual. This technique has both merits and limitations. The visually disabled
individual can feel safe and walk gracefully in the company of the sighted
guide. On the other hand, if the sighted guide is the only helper in travel, the
visually disabled individual will be developing dependence which is not
33
conducive for her or his overall development.
Persons with Disabilities  Long cane technique: The long cane which is popularly known as the
‘white cane’ is widely used by visually disabled individuals. The cane
can help in finding surfaces of different textures, stairs, etc. Visually
disabled person should use certain clues and landmarks while using
long cane for independent travel.
3. Daily Living Skills
Daily living skills may be treated as basic survival skills. These are the
abilities which enable the visually impaired children to carry on their daily
routine without assistance or with minimum assistance. Development of
these abilities instills confidence in the children for their mainstreaming with
non-disabled children. It is often misunderstood that loss of sight means
darkness and incapacity in life. Research studies strongly indicate that it is
not true. Daily living skills develop in an individual only by practice and
therefore, adequate practice should be given to the child.
Now, the main question that arises here is, ‘‘What is to be done for developing
daily living skills?’’.
In daily life, the individual comes across a wide range of events. Combing
the hair may be a minor activity compared to preparation of a complete meal
but both are important in their own ways. How to teach such activities to
the unseeing person is a vital and formidable task. Alternative strategies
have to be worked out if the usual techniques fail. Besides, the strategies and
instructional procedures, criteria for performance assessment are also needed.
Therefore, diagnosis of areas, development of strategies, and evaluation of
performance of daily living skills are equally important. There are no special
daily living skills for visually impaired children. Whatever skills are expected
of a sighted person, the same are also expected of a visually impaired person.
Therefore, considering skills of sighted children as reference, may helps in
planning better strategies for teaching daily living skills to visually disabled
children. The six-stage strategy in teaching daily living skills may be as follows:
i) Observation of the daily living skills exhibited by sighted children at various
grade levels,
ii) Diagnosing the difficulties faced by visually disabled children in acquiring
those skills in a natural manner,
iii) Designing pre-requisite skills after necessary diagnosis of difficulties
encountered by visually disabled children,
iv) Teaching those readiness skills which lead to the learning of daily living
skills,
v) Preparing evaluation criteria to measure the level of acquisition of daily
living skills, and
vi) Evaluating the performance of the children in daily living and suggesting
appropriate remedial measures.
Daily living skills in an individual are vital ingredients for proper social development.
The skills should be in accordance with the norms of any society. The absence
34 of sight in the visually disabled person imposes a restriction on acquiring information
of the world in a natural way. This area needs to be strengthened in the overall Persons with Sensory
Impairments
curriculum of visually impaired children in schools and in rehabilitation programmes.
Teaching these skills to visually disabled children may be difficult but not impossible.
16.5.3 Deaf Blindness
As the popular sayings state ‘early intervention is the best prevention’ or ‘prevention
is better than cure’.
It is vital for medical professionals to be sensitive to their role as the medical care
provider on the team promoting rehabilitative therapies for children with disabilities.
Medical professionals can help in creating an environment in which the physician,
family and other service providers work together in a caring, collegial, and
compassionate atmosphere that ensures that early intervention services are of high
quality, accessible, continuous, comprehensive and culturally competent.
Some of the early interventions that can be used for persons with both visual and
hearing impairments are discussed below:
 Pharmacotherapy: Physicians can recommend the appropriate medicine to
the child after considering the condition of the child.
 Therapeutics: Physicians can play a vital role in guiding the therapists like
physiotherapist, occupational therapist and/or speech therapist. They can
suggest the therapist about the condition of the child, the prognosis, risks for
associated disabilities and the effect of continuing drugs thereby affecting
therapy decisions.
 Clinical assessment: Families of children with multiple disabilities need
support in the area of clinical assessments from doctors. Complete and
appropriate information in a simple manner about the child’s exact condition
is a need for all family members. Appropriate diagnosis for sensory conditions,
epilepsy, degenerative disorders, surgeries, biochemical reactions and so on
is extremely important for families to cope with the every day needs of
children with multiple disabilities. Often after a thorough check up and
diagnosis, families have little idea on what to expect from their child in the
future or their role in the child’s medical intervention. Interpreting the diagnosis
in a simple and straight manner will help the parents to prepare as per the
child’s medical needs.
 Genetic counselling and family counselling: This is a specialised area for
medical professionals and more so in the area of multiple disabilities. Most
causes for disabilities are related to genetic factors. A genetic test, analysis
and counselling at the appropriate time will reduce the occurrence of children
with multiple disabilities and impede the spread of the disability further.

16.6 LET US SUM UP


Sensory impairment refers to difficulty either in seeing or hearing. There are
different levels of disability — some people may not be able to hear at all
while others will be able to hear partly and might use hearing aids. In the same
way a person could be totally blind or able to see partly. Sensory disability
includes hearing disability, visual disability and deaf blindness.
35
Persons with Disabilities When the impairment reduces the child’s functional potential and restricts her or
his level of performance, it becomes a disability. Hearing disability is defined as
the auditory problem experienced and complained by the individual. Visual disability
is of two types that is blindness and low vision. Blindness acuity refers to a
condition where a person suffers from total absence of sight or extremely limited
field of vision or visual acuity not exceeding 6/600 or 20/200 in the better eye
even with corrective lenses or limitations of the field of vision subtending an angle
of 20 degree or worse. Low vision means markedly reduced functional vision in
the individual. Low vision may demand large print materials and magnifiers for
reading. Recent technological advancement has facilitated better learning
opportunities for low vision children. A person with low vision is one who has
impairment of visual functioning even after treatment, for example an operation
and / or standard refractive correction with glasses or lenses.
Assessment of hearing impaired child can be done by direct observation of behaviour
and formal assessment with the help of audiologist, psychologist and speech
therapist. On the basis of the degree of impairment, the hearing loss may be
classified as mild hearing loss, moderate hearing loss, moderately severe hearing
loss, severe hearing loss and profound hearing loss. The assessment and
identification of children or persons with visual disability may be based on the
common features, informal methods such as direct observation and formal
procedures with the help of some assessment tools.
The causes of hearing disability can occur at any time of the developmental period
that is before birth, during birth or after birth. The causes before birth may
concern family history of childhood deafness, consanguineous marriages, illness
during pregnancy, history of mother suffering from rubella during pregnancy and
poor physical condition of the mother. VISION 2020 has identified many causes
of avoidable blindness, among which five conditions have been identified for
immediate priorities. The choice of these conditions is based on the burden of
blindness they represent and the feasibility and affordability of interventions to
prevent and treat them. These are: cataract, trachoma, onchocerciasis, childhood
blindness, refractive errors and low vision. The intervention in the case hearing
diability consists of language and speech therapy, behaviour therapy, family
counselling and fitting of heraing aid and ear mould. For visual disability sensory
training, orientation and mobility and training in daily living skills are important.
The intervention for deaf blindness includes, pharmacotherapy, therapeutics, clinical
assessment, and genetic and family counselling are very important.

16.7 GLOSSARY
Central hearing loss : Hearing loss due to defects in central
auditory processing.
Field of vision : The entire area which can be seen while
the eye remains fixed upon one point in
straight line.
Mixed hearing loss : Hearing loss due to any problem in the
outer and / or middle ear including inner
ear.
Sensori-neural hearing loss : Hearing loss due to any problem in the
36
inner ear and / or auditory nerve.
Persons with Sensory
16.8 ANSWERS TO CHECK YOUR PROGRESS Impairments

EXERCISES
Check your Progress Exercise 1
1. i) seeing
ii) Hearing
iii) Visual functioning
iv) dual
Check Your Progress Exercise 2
1. Visual impairment may be identified with the help of common features
as mentioned below:
Blindness
 Child tilting her or his head to locate the light source,
 Pain and irritation in the eyes,
 Bumping into objects in the environment,
 Unable to write from the blackboard, takes help from peers to copy
from the blackboard,
 Poor performance in the class,
 Unable to read in poor lighting conditions,
 Unable to see during night,
 Depending too much on oral information,
 Rubs eyes excessively,
 Watery eyes,
 Eyelids are often red,
 Holds objects and the book too close to eyes,
 Squints or blinks when looking at something,
 Blinks more frequently, and
 Regular headaches.
Low Vision
 Confident movement in school environment,
 Visual orientation to the new stimuli,
 Light gazing,
 Avoidance response to shadows,
37
Persons with Disabilities  Interested in visual games,
 Avoidance of large obstacles,
 Unusual head tilt,
 Hand flickering,
 Distracted by movement in the environment,
 Startled response to suddenly approaching objects,
 The child experiences difficulty in reading small prints,
 The child experiences difficulty in identifying small details in
pictures or illustrations,
 The child frequently complains of dizziness after reading a passage
or completion of assignments involving vision, and
 The child frequently complains of headache, infection in eye; the
child uses one eye more than the other.
2. Following are the assessment tools used to measure visual functioning:
i) Maddox rod test,
ii) Allied muscle balance test,
iii) Tests of hyperopia,
iv) Plus lens test, and
v) Near vision testing.
Check Your Progress Exercise 3

1. Following are the five types of hearing loss:

i) Conductive hearing loss,

ii) Sensory neural hearing loss,

iii) Mixed hearing loss,

iv) Central hearing loss, and

v) Functional hearing loss.

2. Following are the five causes of avoidable blindness identified by VISION


2020:

i) Cataract,

ii) Trachoma,

iii) Onchocerciasis,

iv) Childhood blindness, and


38 v) Refractive errors and low vision
Persons with Sensory
16.9 UNIT END QUESTIONS Impairments

1. What are the symptoms and features indicative of hearing impairment in a


child?

2. What are the identification processes for deaf blindness?

3. What are the interventions needed for visually impaired persons?

16.10 FURTHER READINGS AND REFERENCES


Berg, F. S. (1976). Educational audiology. New York: Grume & Stratton.

Berg, F. S. (1986). Educational audiology for hard of hearing child. Orlando:


Grume & Stratton.

Ebly, S. W. (1985). Working with parents of exceptional children. St Louis:


Times Mirror.
Martin, F. N. (1991). Introduction to audiology. NJ: Prentice-Hall.
Mc Cracken, W. (Ed.) (2004). Audiology in Education, London: Whurr Pub.
Mukhopadhayay, S., Jangira, N.K. & Mani M.N.G., (1987) Source book for
training teachers of visually impaired, New Delhi: NCERT.
Newby, H. A. (1979). Audiology 4th Ed. NJ: Prentice-Hall.
Northcott, W. H. (1973). Hearing impaired child in a regular classroom.
Washington: Alexander Grahm Bell Assn.
Punavi, B. & Rawal, N. (2000). Visual impairment handbook. Ahmedabad:
Blind Peoples’ Association (India).
Reed, M. (1984). Educating hearing impaired children. Milton Keynes: Open
University Press.
Taylar, R. L. (1993). Assessment of exceptional students. Boston: Allyn &
Bacon.
Wang, M. C, et.al (Eds) (1988-1991). Handbook of special education 4 Vols.
Oxford: Pexgamon Press.

39
UNIT 17 PERSONS WITH MENTAL
RETARDATION
Structure
17.1 Introduction
17.2 Definitions and Classifications
17.3 Causes of Mental Retardation
17.3.1 Genetic Factors
17.3.2 Prenatal Causes
17.3.3 Perinatal Causes
17.3.4 Postnatal Causes
17.3.5 Other Conditions

17.4 Tests for Diagnosis


17.5 Characteristics of Children with Mental Retardation
17.5.1 Physical Characteristics
17.5.2 Cognitive Characteristics
17.5.3 Behavioural Characteristics
17.6 Associated Disorders
17.7 Prevention
17.7.1 Genetic Counselling
17.7.2 Prenatal Care
17.7.3 Postnatal Care

17.8 Intervention
17.9 Role of Community Members
17.10 Let Us Sum Up
17.11 Glossary
17.12 Answers to Check Your Progress Exercises
17.13 Unit End Questions
17.14 Further Readings and References

17.1 INTRODUCTION
Mental retardation is a commonly heard word which refers to a person having
below average intelligence. At all times, in all societies there have been persons
mental retardation. Mental deficiency was a term which was earlier used. Mental
retardation means that the person has limited mental functioning like understanding,
following instructions, memory, recall, communicative abilities, and social skills.
Such persons may be dependent on others and/or may be less capable to take
care of themselves. Because of so many limitations, a child with mental retardation
is slow in learning social skills and intellectual work. Such children may take
longer time than a normal child to speak, walk, take care of themselves, be toilet
trained, learn alphabets and concepts like numbers, time, money and much more.
Such children would learn the skill but need much more practice and time than
an average child. In this Unit, we will learn more about it.
40
Objectives Persons with Mental
Retardation
After studying this Unit, you will be able to:
 Define mental retardation;
 Delineate the causes of mental retardation;
 Describe characteristics of persons with mental retardation; and

 Analyse the role of community in prevention, intervention and care of persons


with mental retardation.

17.2 DEFINITIONS AND CLASSIFICATIONS


Mental retardation has been included in the Persons with Disabilities (PWD) Act
(1995). According to the PWD Act (1995), mental retardation refers to a condition
of arrested or incomplete development of mind of a person, which is specially
characterised by sub normality of intelligence. Any mental disorder other than the
mental retardation is mental illness.

The National Sample Survey Organisation (NSSO) in 2002 categorised mental


disability into mental retardation and mentally illness. Persons with mental retardation
were defined as those persons who have difficulty in understanding instruction,
who do not carry out activities like others of their age group or exhibited behaviors
like talking to self, laughing, crying and scaring, without reasons. Further for a
person to be identified as having mental retardation it was stipulated that the
above conditions must be either present since birth or childhood, or before the
age of 18 years. Typically these persons are late in talking, sitting, standing or
walking. On the other hand mentally ill persons may have difficulty in understanding
instruction, or carrying out their activities like others of their age group and may
exhibit abnormal behaviours like talking to self, laughing or crying, without reasons,
but they do not possess these above conditions since birth or childhood and
before 18 years of age. Moreover, they are not late in talking, sitting, standing or
walking. The PWD Act recognises mental retardation and mental illness as two
different types of disabilities. We will discuss about mental illness in the next Unit.

In this Unit, let us focus on mental retardation. Persons with mental retardation
manifest subnormal cognitive, language, motor and social abilities. Thus, broadly
speaking mental retardation may be referred to as a disability characterised by
significant limitations in both intelligence and adaptive behaviour. This disability
originates before 18 years of age.

World Health Organisation (WHO) classified disabilities through International


Classification of Impairments, Disabilities and Handicaps (ICIDH) in 2001. The
document; referred to as the ICIDH – 2 and International Classification of
Functioning, Disability and Health (ICF) gave the definition for mental retardation.
This definition includes “any person who is unable to ensure himself or herself,
wholly or partly, the necessities of a normal individual or social life including work,
as a result of deficiency in his or her physical or mental capability”. It is a
condition usually characterised by abnormal brain development in the womb that
does not correspond with normal physical growth. The person’s learning ability, 41
Persons with Disabilities
reasoning power and judgement, all develop at a slower pace. Accidents, poisoning,
or illness after birth can be a cause for mental retardation. Many of the persons
with mental retardation can work with the non-disabled people with additional
support and appropriate adaptations. They can be effectively integrated into the
social structure. Mental retardation can be divided into the following four categories:

 Mild mental retardation (IQ : 50 - 70),

. Moderate mental retardation ( IQ : 35-49),

 Severe mental retardation (IQ : 20-34), and

 Profound mental retardation (IQ : under 20).

The definition of mental retardation is given in the tenth revision of the International
Classification of Diseases (ICD-10). It characterises mental retardation as a
condition resulting from a failure of the mind to develop completely. It suggests
that cognitive, language, motor, social, and other adaptive behaviour skills should
be used to determine the level of intellectual impairment. The levels of mental
retardation specified in ICD – 10 (Biasini, et al., 2007) are:

F70 - Mild mental retardation (IQ 50-69)

F71 - Moderate mental retardation (IQ 35-49)

F72 - Severe mental retardation (IQ 20-34)

F73 - Profound mental retardation (IQ below 20)

F78 - Other mental retardation

F79 - Unspecified mental retardation

Other mental retardation, F78, should be used when associated physical or sensory
impairments make it difficult to determine the degree of impairment.
Unspecified mental retardation, F79, should be used when there is evidence of
mental retardation but not enough information to establish a level of functioning.
(Biasini, et al., 2007).

Wikipedia describes mental retardation as a generalised disorder, characterised


by significantly impaired cognitive functioning and deficits in two or more adaptive
behaviours that appears before adulthood. Historically it has been defined as an
Intelligence Quotient score below 70. Now, however, the definition includes a
component related to mental functioning as well as one relating to individuals’
functional skills in their environment.

American Association on Mental Retardation (AAMR), that has in 2007 changed


its name to American Association on Intellectual and Developmental Disabilities
(AAIDD), now prefers to use the term “intellectual disability” rather than “mental
retardation”. It defines intellectual disability as “a disability characterised by
significant limitations both in intellectual functioning (reasoning, learning, problem
solving) and in adaptive behaviour, which covers a range of everyday social and
practical skills. This disability originates before the age of 18”.
42
The ‘Text Revision’ of the Diagnostic and Statistical Manual of Mental Disorders- Persons with Mental
Retardation
IV (DSM - IV TR) divides mental retardation into mild, moderate, severe and
profound categories on the basis of intelligence quotient (IQ) derived from
intelligence tests.

The categories of mental retardation described under DSM-IV TR are given


below:

Category Range of IQ

i) Mild mental retardation - 50-55 to approximately 70

ii) Moderate mental retardation - 35-40 to 50-55

iii) Severe mental retardation - 20-25 to 35-40

iv) Profound mental retardation - Below 20 or 25

The diagnosis on DSM-IV TR is entered on Axis II and for some problems like
autism, bipolar disorder, and schizophrenia, the diagnosis is entered on Axis I.

With “intelligence quotient” or “IQ” being referred to so frequently, let us take a


look at what the term means.

Alfred Binet (1973) introduced the concept of mental age. According to him,
majority of children of a particular age are of normal intelligence and have
mental level approximating that age. Thus, their mental age approximates
their chronological age. From Binet’s work the phrase ‘‘intelligence quotient’’or
‘‘IQ’’, entered the vocabulary. The IQ is the ratio of ‘‘mental age’’ to chronological
age. William Stern (1976) suggested multiplying this ratio by hundred so as to
avoid fractions. Intelligence quotient (IQ) is hence calculated as follows:

IQ = MA  100
CA

where IQ is Intelligence Quotient

MA is Mental Age

CA is Chronological Age
Therefore, if the mental age of a person is the same as his or her chronological
age, the IQ of the person would be 100.

Educational classifications of mental retardation (e.g. Biasini, et al., 2007) tend


to classify children with mental retardation into three groups. These are:

 Educable: Children who can learn simple academic skills but not
progress above fourth grade level.

 Trainable: Children could learn to take care of their daily needs


but very few academic skills.

 Untrainable: Children who were dependent and considered in need


of long term care at home or residential setting.
43
Persons with Disabilities
According to Elkind and Weiner (1978), persons with mental retardation are
generally classified in four categories. These are given in Table 17.1:
Level of IQ Categorisation Characteristics
mental Range of the persons
retardation
Mild 55-69 Educable These people may lag
behind somewhat in their
early development, but
they are seldom identified
as retarded until they enter
elementary school. These
children are also called
slow learners at school.
Moderate 40-54 Trainable These people lag behind
noticeably in developing
communication and motor
skills during the preschool
years and usually cannot
master useful academic
skills.
Severe 25-39 Untrainable or These people usually
Custodial cannot take care of
themselves and require
institutionalisation,
usually early in life.
They may learn basic
self-care skills as
feeding and dressing.
They need total nursing
care themselves.
Profound Below Dependent They may not be able to
25 throughout life feed themselves, control
their bowels movements
or walk.

Table 17.1: Classification of persons with mental retardation according to


educational retardation

Luckasson et al (1992) emphasised on the level of the support needed by the


person with mental retardation. Intensity of support or level of support is measured
as intermittent, limited, intensive and pervasive, which may be described as follows:

 Intermittent support refers to support that is needed but not necessarily


present at all times;

 Limited support refers to support to be provided on a regular basis for a


short period of time;

 Extensive support refers to ongoing and regular involvement of support to


the person; and
44
 Pervasive support refers to support that is constant and of high-intensity. It Persons with Mental
Retardation
involves more staff members and is provided across environments.

These terms are related to mild, moderate, severe and profound categories of
mental retardation, and emphasise the necessary support for the individuals (Kirk
et al, 2006).

Check Your Progress Exercise 1


Note: a) Read the following question carefully and answer in the space
provided below.
b) Check your answer with that provided at the end of this Unit.
1. How has “mental retardation” been defined in the Persons with Disabilities
Act (1995) of our country?

...............................................................................................................

...............................................................................................................

...............................................................................................................

...............................................................................................................

17.3 CAUSES OF MENTAL RETARDATION


Mental retardation could be caused due to various factors. It could be a result
of injury, disease, brain abnormality, genetic disorder, malnutrition, etc. At times,
the cause of mental retardation is unknown. The various known reasons for
mental retardation are discussed below.
17.3.1 Genetic Factors
Mental retardation could be caused by genetic factors that the child inherits from
the parents in the form of chromosomes and genes. In a normal human being,
there are 46 chromosomes or twenty-three pairs of chromosomes, of which
twenty-two pairs are called autosomes or non-sex chromosomes and the twenty
third pair consists of sex chromosomes. Chromosomes are made of genetic
material called genes. Each gene within these pairs of chromosomes has a duplicate
gene on the matching chromosome (details of this you have read in Course
MCFT-001, Unit – 2). Deformities may occur during the formation of ovum or
sperm. The error occurs when the process of meiosis takes place. The resultant
mental retardation conditions are:
1. Down Syndrome: Down syndrome is also called mongolism. The person
has an extra or deviant chromosome. Down syndrome individual has
21st chromosome genetic disorder. Down syndrome is named after the
physician who first described it. This is of three types:
i) Trisomy 21: In this, there is an extra 21st chromsome. Instead of
having a pair of 21st chromsome, the person has a triplet of 21st
chromosome causing a condition called trisomy.
45
Persons with Disabilities
ii) Masoicism (Mosaic type): In this the person shows trisomy 21st
only in a portion of the analysis of blood or skin cells and the rest
shows normal 46 chromsomes. So, some parts of the body have faulty
development while the other body parts have normal development.
iii) Translocation: In this, extra chromosomal material, that is, whole or
part of chromosome is attached to another chromosome. In simple
words, all or part of the extra chromosome of the twenty-first pair
becomes attached to another chromosome pair.
2. Phenylketonuria (PKU) : It involves the inability of the body to convert
an amino acid  phenylalanine found in protein foods to tyrosine due
to lack of the enzyme needed for the purpose. The accumulation of
phenylalanine leads to abnormal brain development and may result in
severe mental retardation. A special low protein diet helps to reduce and
improve this condition.
3. Tay–Sachs disease: It happens when both mother and father are carriers
of this disease. It results in progressive brain damage and eventually
death of the person.
4. Cri-du-chat syndrome or Prader-Willi syndrome: It is an autosomal
abnormality and is caused due to deletion of 4th – 5th chromosomes.
5. Fragile X Syndrome: It happens from a mutation on the long arm of the
X chromosome, and it affects about twice as many males as females – about
once in four thousand (Kirk et al, 2006). Fragile X syndrome is the most
common form of inherited mental retardation.
Other reasons for mental retardation could be:
 Trisomy 13-15
 Trisomy-18
 Klinefelter syndrome
 Turner syndrome
 Triple X syndrome
You would recollect reading about some of these factors in Unit-2 of Course
MCFT-001.

17.3.2 Prenatal Causes


The mal-development of the embryo or foetus resulting in mental retardation
occurs due to the following factors during pregnancy:
– German measles (Rubella) in the first trimester (first three months) of
pregnancy,
– Toxemia,
– Syphilis,
– Influenza,
– Encephalitis,
46
 Incompatibility between the Rh factor and blood group of the mother’s Persons with Mental
Retardation
blood and that of the foetus.
 Consumption of alcohol during pregnancy leads to foetal alcohol
syndrome(FAS).
 Smoking (nicotine), coffee (caffeine), tea (tannins) have a harmful effect
on foetus,
 Heavy metals like lead, cadmium, mercury affect the prenatal
development of human brain,
 Drugs both medicinal and non-medicinal like cocaine, opium, smack
etc. have a harmful effect on the growing foetus,
 Radiation like X-rays, etc. are quite harmful to the foetus, and
 Oxygen deprivation to the foetus or embryo leads to depletion of brain
cells and therefore, mental retardation.

17.3.3 Perinatal Causes


The perinatal causes are the factors that result in mental retardation during
the birth process. These are given below:
 During the birth process, lack of oxygen (called anoxia) to the central
nervous system results in mental retardation,
 Use of forceps during birth may fracture the skull and cause brain damage,
and
 Neonatal jaundice.

17.3.4 Postnatal Causes


Postnatal causes are also known as after birth factors that can lead to mental
retardation. These are listed below:
 Illness like meningitis, encephalitis, whooping cough or measles,
 Asphyxia under anesthesia or from drowning or cardiac arrest may lead
to permanent brain damage,
 Malnutrition and lack of protein during early childhood years has an
adverse effect on intellectual functioning, and
 Niemann - Pick disease is a disorder of lipid metabolism during early
infancy which may cause mental retardation.

17.3.5 Other Conditions


There are some other conditions also that may cause mental retardation, these
are:
 Cranial anomalies: In this, there are alterations to the size and shape of the
head. It is of three types:
a) Macrocephalus : In this, there is an abnormal increase in the size and
weight of the brain.
47
Persons with Disabilities
b) Microcephalus : In this, there is a decrease in the size and weight of
the brain.
c) Hydrocephalus : In this, a rare disorder, there is an abnormal amount
of cerebro-spinal fluid within the cranium causing its enlargement and
damage to brain tissue.
 Head injury,
 Stroke,
 Iodine deficiency,
 Severe sensory deprivation,
 Severe atypical parent-child interactions, and
 Psycho-social disadvantage like poor diet, poor health practices, poor housing,
and use of such language which is not common in the community.

Check Your Progress Exercise 2


Note: a) Read the following questions carefully and answer in the space
provided below.
b) Check your answers with those provided at the end of this Unit.
1. Fill in the Blanks:
st
i) In ......................................, the presence of an extra 21 chromosome
leads to mental retardation.
ii) The interited inability of the body to convert phenylalanine leads to
..................................
iii) Lack of oxygen at the time of birth is called..............................

17.4 TESTS FOR DIAGNOSIS


Mental retardation is diagnosed mainly through assessment of :
 Intelligence Quotient (IQ) of the child: In this, the child’s ability to think,
learn and solve problems is tested on various intelligence tests.
 Social adaptability of the child: In this, an assessment is made of the
child’s ability to master the social skills that are necessary for independent
living, including the child’s learning of daily living skills such as dressing,
toileting, feeding, etc; communication ability such as to understand what is
told, to follow the instructions and give appropriate reply; and social skills
necessary to mix with others in social groups like parents, family, teachers,
peers and community.
One can diagnose mental retardation through use of the following tools.
Intelligence or Cognitive Developmental Assessment Tools:
Some of the commonly used intelligence or cognitive development assessment
tools are given below:
 Bayley Scales of Infant Development (BSID) – Second Edition
48  The Differential Ability Scales (DAS)
 Wechsler Preschool and Primary Scale of Intelligence – Revised Persons with Mental
Retardation
(WPPSI-R)
 Wechsler Intelligence Scale for Children – Revised (WISC – R)
 Performance Intelligence Test Battery by Dr. C.M. Bhatia
 Indian adaptation of Wechsler Intelligence Scale for Children by A. J.
Malin
 General Mental Ability Test by R.P. Srivastava and Kiran Saxena
 Seguin Form Board Test adapted by J. Bharat Raj and S.K Goyal for
Indian Children.
 Stanford – Binet Intelligence Scale – Fourth Edition.
 McCarthy Scales of Children’s Abilities
 Draw A Man Test – Good Enough
 Draw A Man Test – Pramila Phatak
 Raven’s Progressive Matrices (RPM)
- The Standard Progressive Matrices (SPM)
- The Coloured Progressive Matrices (CPM)
- The Advanced Progressive Matrices (APM)
Adaptive Behaviour Assessment:
To assess adaptive behaviour, the following scales are commonly used:
 Vineland Adaptive Behaviour Scales (VABS)
 The American Association on Mental Retardation (AAMR) Adaptive
Behaviour Scale (ABS)
Achievement Tests:
Following achievement tests are also used to assess mental retardation:
 Woodcock-Johnson Psycho-Educational Battery – Revised.
 The Wide Range Achievement Test – Revised (WRAT-R).
Other Tests:
Some other test and scales that are useful in assessing mental retardation are given
below:
 Peabody Picture Vocabulary Test – Revised (PPVT – R)
 Columbia Mental Maturity Scale
 Leiter International Performance Scale
Other Techniques to Assess Mental Retardation
In addition to standardised scales, tests and batteries there are some other
techniques, which are useful for assessment of mental retardation. These are: 49
Persons with Disabilities
 Interviews
 Observations
 Informal assessment

Check Your Progress Exercise 3


Note: a) Read the following questions carefully and answer in the space
provided below.
b) Check your answers with those provided at the end of this Unit.
1) What are the two key aspects that are assessed for diagnosing mental
retardation in a child?
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
2) Name two intelligence tests developed in India.
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
3) Name two adaptive behaviour assessment scales.
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................

17.5 CHARACTERISTICS OF CHILDREN WITH


MENTAL RETARDATION
Some of the characteristics of children with mental retardation have been grouped
under physical characteristics, cognitive characteristics and behavioural
characteristics in this section.
50
17.5.1 Physical Characteristics Persons with Mental
Retardation
Let us take a look at the physical characteristics commonly found among children
with mental retardation. These characteristics include physical features, somatic
development and motor abilities. Head circumference of children with mental
retardation is often less than the normal children, which can be seen in the case
of microcephalus. However, if the child has hydrocephalus, the head circumference
is larger than normal as the head is filled with fluid. Children suffering from Down
syndrome tend to have short and stout stature, thick fingers or club fingers and
toes, moon shaped eyes, small nose, wide spacing between eyes, mouth usually
open and fissures in the tongue, and saliva coming out of mouth.
Children with mental retardation generally have a clumsy gait and may also give
blank looks. They may have hoarse or broken voice. The growth and development
of these children follows the same developmental pattern as of normal children but
their abilities are quite delayed, depending upon their mental age. Motor activities
like walking on one line, jumping, hopping, etc. develop according to the mental
or intellectual functioning of the child.
17.5.2 Cognitive Characteristics
Let us now consider the cognitive or mental or intellectual characteristics of
children with mental retardation. These children cannot concentrate for long
time and are unable to keep their attention on anything for long time. It is a major
task to keep them occupied in one activity for a significant duration; say 15 to
20 minutes. Poor memorisation and forgetfulness is common among such children.
They have very short term memory and rehearsing is poor among such children.
They may have speech and language problems. As the level of retardation goes
higher, language problem becomes severe. The capability of information processing,
organising, classification, generalisation among these children is less developed as
compared to a non-disabled child. In severe cases, the higher order of cognitive
functioning is less developed. Higher mental abilities like decision making, analysis,
synthesis, problem solving, cause and effect relationship, etc. are not present
among these children.
The academic performance of these children is less than their normal peers.
Understanding of concrete objects is present, but abstract thinking is not
seen. They can follow verbal instruction which are repeated frequently, but
they cannot memorise the instructions.
17.5.3 Behavioural Characteristics
The behavioral and personality characteristics of persons with mental
retardation are different from their normal peers. They display difference in
social and emotional behaviours which at times, results in social and emotional
problems. Their self motivation level is low and they avoid leading and initiating
any activity. They have low self-confidence. They cannot face challenges and
easily give up. They have problems in social gathering and avoid situations which
involve gathering of many people. They have low self-esteem and self concept.
Their social interaction is limited. They may exhibit self injurious behaviours. They
tend to engage in repetitive behavioral activities. Creativity among these children
is low. They generally, prefer to play with children of lower age group than their
age mates. 51
Persons with Disabilities
Check Your Progress Exercise 4
Note: a) Read the following question carefully and answer in the space
provided below.
b) Check your answer with that provided at the end of this Unit.
1. What are the physical characteristics of children with Down syndrome?
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................

17.6 ASSOCIATED DISORDERS


McLaren and Bryson (1987) said that a variety of disorders are associated with
mental retardation like epilepsy, cerebral palsy, vision and hearing impairments,
speech or language problems and behaviour problems. Baird and Sadovnick
(1985) stated that the number of associated disorders appears to increase with
the level of severity of mental retardation. We will discuss some of these disorders
in detail in the next Unit.
Check Your Progress Exercise 5
Note: a) Read the following question carefully and answer in the space
provided below.
b) Check your answer with that provided at the end of this Unit.
1 State any four associated problems which persons with severe mental
retardation may suffer from.
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................

17.7 PREVENTION
Some of the measures discussed below could help in preventing mental retardation
to a large extent.

17.7.1 Genetic Counselling


Avoid late pregnancy as far as possible. One should go for genetic counselling as
genetic factors make a significant contribution to mental retardation. Pre-natal
assessment would prepare the new parents about the coming problems. We
have discussed these tests and procedures in Unit 2 of Course MCFT-001.
52 Consanguineous marriage should be avoided.
Persons with Mental
17.7.2 Prenatal Care Retardation
During pregnancy proper care of mother is important. Vaccination for German
measles or rubella at least three months before conceiving is advisable. Proper
nutrition and health care of the mother is necessary. Expectant mothers should
avoid alcohol, smoking, drugs and irradiation as these are very harmful to the
foetus as well as for their own health. Good nutritious diet needs to be given to
the pregnant woman including dietary supplements like iron and calcium tablets.
Proper medical care is equally important.
17.7.3 Postnatal Care
Proper medical facility at the time of birth should be present. Preferably, delivery
of child should be done at hospitals or nursing homes or under the supervision of
trained medical personnel. Immediate treatment of new born baby for jaundice
should be given. Proper schedule of immunisation during childhood should be
followed strictly. Care should be taken to prevent occurrence of head injuries and
accidents. Food of good nutritive value should be given to young children. A
nurturant and stimulating physical, social and mental environment should be
provided to the child.
Check Your Progress Exercise 6
Note: a) Read the following question carefully and answer in the space
provided below.
b) Check your answer with that provided at the end of this Unit.
1. Write a short note on prenatal care.
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................

17.8 INTERVENTION
Appropriate interventions for the child with mental retardation are important for
the child’s optimum development, including social adjustment, psychological
well-being and educational growth. Intervention has to be need based, that means
depending on the needs and requirements of a particular child. Intervention can
be given in a group of similar children with similar needs and problems like same
IQ, social skills, adaptive behaviour etc. It has to be given in the least restrictive
environment to the child. Professional trained educators and sensitised parents
can teach and help the child with mental retardation. The child should be provided
opportunities to interact with non-disabled peers and community members.
 Intervention for Infant
Counselling, family therapy, parent training, language services, assistive technology,
intervention for sensory organs, nutrition counselling, occupational therapy and
physiotherapy may be provided to the infant who is suffering from mental
retardation. It could be home based or institution based. 53
Persons with Disabilities
 Intervention for Preschool and School Child

The services for preschool and school going child are mostly centre based.
Individualised Education Plan (IEP) should be used even for children in the
same classroom. Both parents and teachers coordinate with each other to
maximise their child’s learning and achievement. The intervention services
mentioned for infant can also be used here.

 Social Intervention

Participation with non-disabled peers in social functions and family ceremonies


like birthday party, sports, marriage, etc. benefit in teaching appropriate social
skills to the child with mental retardation. Parent support group meetings of
children with mental retardation should be frequently held so that parents and/
or caregivers get the opportunity to express their feelings, share experiences and
learn from others’ experiences.

 Education for Children with Mild and Moderate Mental Retardation

During early elementary school, emphasis is more on providing the children with
readiness skills and development of abilities that are prerequisites for later learning.
Hallahan and Kauffman (1991), said that these include such activities as the
ability to:

1. Sit still,

2. Obey teacher,

3. Discriminate auditory and visual stimuli,

4. Follow directions,

5. Develop language,

6. Increase gross and fine motor coordination,

7. Develop self help skills, and

8. Interact with peers in a group situation.

 Education for Children with Severe and Profound Mental


Retardation

Educational programmes for children with severe and profound mental retardation
according to Hallahan and Kauffman (1991) should include the following:

1. Age appropriate curriculum and materials,

2. Functional activities,

3. Community based instruction,

4. Integrated therapy among a variety of professionals such as speech, physical


and occupational therapists,

5. Interaction with non-disabled students, and

6. Family involvement.
54
Persons with Mental
Check Your Progress Exercise 7 Retardation

Note: a) Read the following questions carefully and answer in the space
provided below.
b) Check your answers with those provided at the end of this Unit.
1. Outline school-level intervention strategies for the children with mild
mental retardation.
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
2. Write a short note on social intervention.
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................

17.9 ROLE OF COMMUNITY MEMBERS


Environment effects learning of all children  whether normal or those with mental
retardation. Role of the community members hence become important. Community
members dealing with a child with disability need to be more compassionate,
patient and skillful in meeting the challenges of the child. Teachers and parents
influence the child the most.
 Teachers
Special educators play a significant role for children with mental retardation.
Many children go to normal schools and attend special classes. All schools follow,
or should follow, an Individualised Education Programme ‘IEP’ to teach the child
according to the child’s unique abilities, needs and requirements. A well organised
and structured classroom environment should be provided. Teachers need to
motivate the child to learn. Tools, equipment and materials present in the classroom
should be child friendly. Teachers can help the child learn things using concrete
experiences and simple verbatim. Teachers should also involve children in group
activities. Parents of these children should be taken into confidence and both
parents and teachers should work together for the child’s optimum growth. Both
parents and teachers should follow the same educational plan at a given time.
Repetition and reinforcement are two important methods of teaching a child with
mental retardation.
 Parents
Parents need to overcome their shock and grief quickly to take care of their child
with the disability. They should learn more about their child. Parents should consult
counsellors and family therapist to help them to deal with this situation and develop 55
Persons with Disabilities
resilience to help their children realise their potential. They should encourage and
motivate their child to do things rather than making the child dependent on
themselves. They should include their child in family functions and celebrations.
Parents should be in constant touch with the teachers. They should follow the
same educational plan as of teachers. Repetition, reinforcement along with
motivation, encouragement, providing opportunities to act and do are important
teaching methods for the parents of the child who suffers from mental retardation.
Parents should also participate in parent support groups to share their experiences,
feelings and concern with others having similar difficulties. The stress among
parents is high on discovery of the problem and also when the child reaches
adolescence and adulthood. Rehabilitation through educational and vocational
training should be done.
Check Your Progress Exercise 8
Note: a) Read the following question carefully and answer in the space
provided below.
b) Check your answer with that provided at the end of this Unit.
1. Write a short note on the role of parents in taking care of children with
mental retardation.
.................................................................................................................
.................................................................................................................
.................................................................................................................

.................................................................................................................
.................................................................................................................

17.10 LET US SUM UP


 Mental retardation commonly means a person having below average
intelligence. A person with mental retardation has limited mental or cognitive
functioning, communication skills and social skills.
 Mental retardation is one of the disabilities mentioned in the Persons with
Disabilities Act, 1995 (PWD Act, 1995) of India. According to the Act,
mental retardation is a condition of arrested or incomplete development of
mind of a person which is specially characterised by subnormality of
intelligence.
 General categories of mental retardation are:

i) Mild retardation with IQ 50-70

ii) Moderate retardation with IQ 35-49

iii) Severe retardation with IQ 20-34

iv) Profound retardation with IQ under 20

 Mental retardation can be caused due to genetic factors, prenatal, perinatal


and postnatal causes.
56
 Mental retardation can be diagnosed using intelligence tests and social adaptive Persons with Mental
Retardation
ability tests on the child.

 A child with mental retardation lags behind the normal child in all the
developmental domains and milestones like to sit, stand, walk, toilet training,
speech etc.

 Children with mental retardation may suffer from other problems like epilepsy,
cerebral palsy, vision and hearing impairments as well.

 Mental retardation in a child can be prevented by avoiding late pregnancy,


adequate care and treatment during pregnancy, proper immunisation, avoiding
head injuries etc.

 Interventions by educators, family counsellors, parent training and assistive


technology are used to benefit children with mental retardation.

 Role of community members, teachers and parents is significant for the


optimum development of a child with mental retardation.

17.11 GLOSSARY
Anoxia : Lack of oxygen at the time of birth

CA : Chronological Age
IEP : Individualised Education Plan
IQ : Intelligence Quotient
MA : Mental Age
Mental retardation : A condition of arrested or incomplete
development of mind of a person which is
specially characterised by sub normality of
intelligence.
PKU : Phenylketonuria
PWD Act : Persons with Disabilities Act.

17.12 ANSWERS TO CHECK YOUR PROGRESS


EXERCISES
Check Your Progress Exercise 1
1. PWD Act (1995) defines mental retardation as a condition of arrested or
incomplete development of mind of a person, which is specially characterised
by subnormality of intelligence.
Check Your Progress Exercise 2
1. i) Down syndrome

ii) Phenylketonuria (PKU)


57
iii) anoxia
Persons with Disabilities
Check Your Progress Exercise 3

1. i) Intelligence Quotient (IQ) of the child

ii) Social adaptability of the child

2. Following are two intelligence tests developed in India:

i) Performance Intelligence Test Battery by Dr. C.M. Bhatia

ii) General Mental Ability Test by R.P. Srivastava and Kiran Saxena

3. Following are two adaptive behaviour assessment scales:

i) Vineland Adaptive Behaviour Scales (UABS)

ii) The American Association on Mental Retardation (AAMR) Adaptive


Behaviour Scale (ABS).
Check Your Progress Exercise 4
1. The physical characteristics of children with Down syndrome are:
i) Short and stout stature,
ii) Thick fingers or club fingers and toes,
ii) Moon shaped eyes,
iv) Small nose,
v) Wide spacing between eyes,
vi) Mouth is usually open and fissures in the tongue, and
vii) Saliva comes out of mouth.
Check Your Progress Exercise 5
1. Following are the associated problems which persons with severe mental
retardation may suffer from (any four):
i) Epilepsy
ii) Cerebral palsy
iii) Speech and language problems
iv) Behavioural problems
v) Visual impairment
vi) Hearing impairment
Check Your Progress Exercise 6
1. During pregnancy proper care of mother is important. One should be
vaccinated for German measles or rubella at least three months before
conceiving. Proper nutrition and health care management of the mother is
necessary. Expectant women should avoid alcohol, smoking, drugs and
irradiation as these are very harmful to the foetus as well as for their own
58 health. Good nutritious diet needs to be given to the pregnant woman including
dietary supplements like iron and calcium tablets. Proper medical care is Persons with Mental
Retardation
equally important.
Check Your Progress Exercise 7
1. School-level intervention strategies for children with mild mental retardation
include encouraging the child to:
i) Sit still,
ii) Obey teacher,
iii) Discriminate auditory and visual stimuli,
iv) Follow directions,
v) Develop language,
vi) Increase gross and fine motor coordination,
vii) Develop self help skills, and
viii) Interact with peers in a group situation.
2. Participation with non-disabled peers in social functions and family ceremonies
like birthday party, sports, marriage, etc. benefit in teaching appropriate
social skills to the child with mental retardation. Parent support group meetings
should be frequently held so that parents and/or caregivers of the children
with mental retardation get the opportunity to express their feelings, share
experiences and learn from others’ experiences.
Check Your Progress Exercise 8
1. Parents need to overcome their shock and grief quickly to take care of their
child suffering from mental retardation. They should learn more about their
child. Parents should consult counsellors and family therapist to help them to
deal with this situation and develop resilience to help their children realise
their potertial. They should encourage and motivate their child to do things
rather than making the child dependent on themselves. They should include
their child in family functions and celebrations. Parents should be in constant
touch with the teachers. They should follow the same educational plan as of
teachers.

17.13 UNIT END QUESTIONS


1. How can you assess the child for mental retardation?
2. How can one prevent mental retardation?
3. What is the role of intervention in the life of a child with mental retardation?

17.14 FURTHER READINGS AND REFERENCE


Baird, P.A. & Sadovnick, A.D. (1985). Mental retardation in over half a million
conservative live births: An epidemiological study. American Journal of Mental
Deficiency, 89, 323 – 330.
Biasini, F.J., Grupe, L., Huffman, L. & Bray, N.W. (2007). Mental reatardation:
A symptom and a syndrome. In S. Netherton, D. Holmes, and C.E. Walker 59
Persons with Disabilities
(Eds.), Comprehensive Textbook of Child and Adolescent Disorders. New
York: Oxford University Press, in press. www.uab.edu/cogdev/mentreta.htm dated:
01/08/2007.
Binet, A. (1973). As in Udaya Shankar, Exceptional Children : Starling Publication
Pvt. Ltd.
Current situation of persons with disabilities (2006). Retrived December 29,
2006, from http://www.apcdproject.or(,)/countryprofile/india/indi current.html
Elkind and Weiner. (1978). Development of the child. New York: John Wiley
& sons, Inc.
Grossman, H.J. (1983). Classification in mental retardation. Washington, DEC:
American Association on Mental Deficiency.
Hallahan and Kauffman (1991). Exceptional Children: Introduction to special
Education. Englewood Cliffs, N.J.: Prentice Hall International Editions.
Kirk, (1953). Educating Exceptional Children. New Delhi: Oxford & IBH
Publishing Co.
Kirk, G.I. & Coleman. (2006). Educating exceptional children. Eleventh Edition.
Boston: Houghton Mifflin Company.
Kirk, Karnes & Kirk. (1955). You and your retarded child. New York:
Macmillan.
Luckasson, R., Coulter, D., Polloway, E., Reiss, S., Schaleck, R., Snell, M.,
Spitalnek, D. & Stark, J. (1992). Mental retardation: Definition, classification
and systems of support. Washington, DC: American Association on Mental
Retardation.
Mangal, S.K. (2007). Educating Exceptional Children: An introduction to
special education. New Delhi: Prentice Hall of India Pvt. Ltd.
McLaren, J. and Bryson, S.E. (1987). Review of recent epidemiological in mental
retardation: Prevalence, associated disorders and etiology. American Journal of
Mental Retardation, 92, 243 – 254.
Mental Retardation. (January 2004). A publication of the National Dissemination
Centre for Children with Disabilities. Fact Sheet 8 (FS 8). Retrieved August 13,
2007 from File://D:/AMR/Disability Info Mental Retardation Fact Sheet (FS 8).htm
Mental Retardation. From Wikipedia File://D:/MR/Mental Retardation
Mental Retardation. <File://D:/AMR/Mental Retardation.htm> dated: 13/07/2007.
Mental Retardation: Developmental Disabilities. Centres for Disease Control and
Prevention. National Centre on Birth Defects and Developmental Disabilities,
dated October 29, 2005. File://D:/MR/Mental Retardation, DD, NCBDDD,
CDC,htm, dated: 13/07/2007.
Puri, M. & Sen, A.K. (1989). Mental retarded children in India. New Delhi:
Mittal Publications.
Singh, A.N. (2001). Enabling the differently able. New Delhi: Shipra Publishers.

60
Stern, W. (1976). As in Enabling the differently able by A.N. Singh. New Persons with Mental
Retardation
Delhi: Shipra Publishers.
The American Association on Intellectual and Developmental Disabilities (AAIDD).
(2007). Mental retardation No more-New Name is Intellectual and Developmental
Disabilities. Retrieved August 13, 2007 from File:// D:/MR/AAIDDJ/Home
Page.htm.
Wikipedia, the free encyclopedia.htm dated: 13/07/2007.
World Health Organization (2007). ICIDH-2: International Classification of
Functioning and Disability. Retrieved August 13, 2007 from www.deakin.edu.au.
Zutshi, B. (n.d.). Disability – Definition, types and international national initiatives.
Retrieved August 13, 2007 from http://www.disabilityindia.or~,’/statusBook
Main.html.

61
UNIT 18 MENTAL ILLNESS AND
PSYCHOSOCIAL
REHABILITATION
Structure
18.1 Introduction
18.2 Mental Illness and Disability
18.2.1 Clinical Characteristics of Psychiatric Disability
18.2.2 Prominent Severe Mental Illnesses

18.3 Psychosocial Rehabilitation


18.4 Historical Perspective
18.5 Magnitude of the Problem
18.6 Present Scenario
18.7 Strategies of Management in Psychosocial Rehabilitation
18.8 Legal Aspects, Advocacy and Community Participation
18.9 Role of Counsellor and Family Therapist
18.10 Let Us Sum Up
18.11 Glossary
18.12 Answers to Check Your Progress Exercises
18.13 Unit End Questions
18.14 Further Readings and References

18.1 INTRODUCTION
Mental illness is not a new term in the world of disability. It is seen that a
person who is suffering from a severe mental illness is often unable to perform
even daily routine activities. To overcome this condition, psychosocial rehabilitation
is a good option along with the medicines. Psychosocial rehabilitation is a process
to restore social functioning and wellbeing of a person who is suffering from
mental illness.
We will learn about mental illness and the diability caused due to this, in this Unit.
Further, we will study about psychosocial rehabilitation. We will get acquainted
with the historical perspectives of services provided for mental illness and
also study the magnitude of the problem. Proper strategies are required to
manage the psychosocial rehabilitation in the area of mental illness. We will
discuss these strategies in this Unit. Community participation is necessary
for the success of psychosocial rehabilitation. We will learn how the family and
the community can help the persons with mental illness. To conclude the Unit, we
will discuss the role of the counsellor and family therapist in dealing with mental
illness. 62
Objectives Mental Illness and
Psychosocial
After studying this Unit, you will be able to: Rehabilitation

 Know about disability arising out of mental illness and its features;
 Learn what is psychosocial rehabilitation;
 Gain knowledge about historical aspect and magnitude of the problem;
 Explain existing provision of services for the mentally ill person; and
 Understand strategies of psychosocial rehabilitation of persons with mental
illness.

18.2 MENTAL ILLNESS AND DISABILITY


The Persons with Disabilities (Equal Opportunities, Protection of Rights and Full
Participation) Act, 1995 has included “mental illness” in its ambit of definition of
“disability”. According to the Act, “mental illness” means mental disorder other
than mental retardation.
Mental illness is a term that describes a wide range of mental and emotional
conditions. Mental illnesses causing disability are prolonged and chronic in nature.
Now they are known as severe mental illnesses. Severe mental illnesses, which
require psychosocial rehabilitation, include chronic schizophrenia, long standing
bipolar illness, persisting depression, delusional disorders and dementias.
Disability arising out of severe mental illness is also known as psychiatric disability.
This disability is defined as a substantial limitation in a major life activity (Liberman,
1993). World Health Organisation (WHO) defines this disability as an inability to
participate or perform at a socially desirable level in such activities as self care,
social relationship, work and situationally appropriate behaviour.
18.2.1 Clinical Characteristics of Psychiatric Disability
Depending on age, gender, education, profession, income, sociocultural
background, diagnosis, and other factors, severely mentally ill persons vary greatly
in many respects. They do, however, have a number of features in common.
These common features, usually seen among persons with severe mental illness,
are categorised into three groups of handicapping factors namely intrinsic, extrinsic
and secondary factors (Wing, 1978, 1981).
 Intrinsic factors: Intrinsic or primary factors consist of continuing psychiatric
symptoms that are part of the illness itself, that is, thought disorder, delusions
and psychomotor retardation. One to two thirds of discharged chronic
schizophrenic patients are significantly disabled by psychiatric symptoms.
 Extrinsic factors: Extrinsic factors include premorbid handicaps such as
lack of social or vocational skills and intellectual or physical disabilities. A
number of researches have concluded that 20 to 50 per cent of severally
mentally ill persons have no friends and only a minority has any significant
community involvement. Those who are married and employed or who have
an active social life are much less likely to join the ranks of a person with
severe mental illness. Even when they do enter this category, they tend to
function at a higher level than those who are single, unemployed or socially
isolated. 63
Persons with Disabilities
 Secondary factors : Secondary factors represent maladaptive reactions to
the illness rather than being part of the illness itself, and include loss of self
esteem, low self-confidence, helplessness and passivity.

18.2.2 Prominent Severe Mental Illnesses


Two major severe mental illnesses namely chronic schizophrenia and bipolar
affective disorder are primarily more prominently covered under the psychosocial
rehabilitation of severely mentally ill.
 Chronic Schizaphrenia
Clinical characteristics of prolonged schizophrenic illness or chronic schizophrenia
are as follows:
i) Chronic deteriorating course and
ii) Disorganised behaviour like, violence, inappropriate affect, self neglect,
wandering and thought disorder.
From the management point of view, symptoms of schizophrenia are categorised
into two groups; these are, positive symptoms and negative symptoms. Positive
symptoms signify an excess or distortion of normal functions, whereas negative
symptoms reflect a diminution or loss of normal functions (DMS-IV; APA 1994).
Negative symptoms are more difficult to treat and are more disabling than positive
symptoms. The main features of positive and negative symptoms are listed in
Table 18.1.
Table 18.1 : Features of positive and negative symptoms

Positive Symptoms Negative Symptoms

Include distortion and exaggeration of: Include losses or deficit in:

I. Thinking and ideas (delusions), I. The range and intensity of emotional


expression,
II. Perception and sensation II. The fluency and productivity of thought
(hallucinations & illusions), and speech (alogia), and

III. Language and communication III. The initiative of goal directed behavior
(disorganized & bizarre (avolition).
speech), and

IV. Behaviour self control


(grossly disorganised).

 Bipolar Affective Disorder


Bipolar affective personality disorder (BAPD) often occurs in the form of episodes
with intervening periods of normalcy and improvement. Further, cyclic episodes
of mania and depression intermittently affect the victim. Phase of mania is
characterised by elation-euphoria, overactivity, grandiosity, decreased need of
sleep and interfering behaviour. During the phase of depression, one suffers
depressed mood, psychomotor retardation, hopelessness, lack of energy, and
decreased appetite and sleep.
During intervening periods some of the features seen are mild symptoms, irritability,
64 mood fluctuations and psychosocial dysfunction.
A typical “chronically (currently, the term in use is severely) mentally ill” person Mental Illness and
Psychosocial
might be expected to have (Bachrach, 1988): Rehabilitation
i) Diagnosis of schizophrenia or major affective psychosis;
ii) At least two admissions in the last year or six months; and
iii) Significant problems of functioning in at least two of the following
areas:
 Basic literacy,
 Self care,
 Financial support (including money management),
 Housing (poor quality or unstable),
 Lack of social support,
 Lack of occupation or employment, and
 Difficulties with close relationships.
In addition, they are likely to show:
 Poor compliance with prescribed medication,
 Some degree of drug or alcohol abuse,
 Difficulties in sustaining follow up and after care,
 Frequent crisis and re-admissions, and
 Significant history of self harm, self neglect or harm to others .
Social Security Administration of America identified four key areas of psychiatric
disability (Liberman,1993). These are listed below:
1. Activities of daily living (for example, grooming, hygiene, maintaining a
household, managing finances);
2. Social functioning (for example, with family, friends, community and in the
workplace);
3. Concentration, pace and task persistence (ability to function for 6 to 8 hours
without supervision); and
4. The ability to tolerate competitive work.

Check Your Progress Exercise 1

Note: a) Read the following questions carefully and answer in the space
provided below.

b) Check your answers with those provided at the end of this Unit.

1. Fill in the blanks:

i) .......................... occurs in the form of episodes with intervening periods


of normalcy and improvement.
------------------------------------------------------------------------------------------ 65
Persons with Disabilities ------------------------------------------------------------------------------------------
ii) .............................. is characterised by elation-euphoria, over activity,
grandiosity, decreased need of sleep and interfering behaviour.
iii) During ........................... periods of bipolar affective disorder, some of
the features seen are mild symptoms, irritability, mood fluctuations, and
psychosocial dysfunction.
2. What are the key areas of psychiatric disability?
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................

Let us now take a look at the crucial aspect of psychosocial rehabilitation in the
case of mental illness.

18.3 PSYCHOSOCIAL REHABILITATION


Psychosocial rehabilitation is a process that facilitates the opportunity for the
individuals who are impaired, disabled, or handicapped by a mental disorder to
reach their optimal level of independent functioning (Rangnathan, 1999).
Psychosocial rehabilitation aims to provide the optimal level of functioning of
individuals and societies, and minimisation of disabilities and handicaps, stressing
individual’s choices on how to live successfully in the community (Rangnathan,
1999).
Goals, Values and Principles of Psychosocial Rehabilitation: Mental health
experts and organisations have outlined goals, values, and principles of psychosocial
rehabilitation (Anthony et. al. 1983, Anthony et. al. 1990, Cnaan et. al. 1988,
1989, 1990 and IAPSRS, 1996). The goals, values and guiding principles identified,
may be summarised as follows:
1. Goals
i) Recovery from mental illness : It is a basic prerequisite of psychosocial
rehabilitation in terms of symptom management. Compliance with
medication plays an important role with the support of family and treating
psychiatrist. Noncompliance of medication retards the process of
psychosocial rehabilitation.
ii) Integration in the family and community : It is a prominent goal to
be achieved with all the efforts of psychosocial rehabilitation. Integration
of person with severe mental illness in the family and community is the
key determinant in the success of psychosocial rehabilitation.
iii) Better quality of life : It needs to be ensured at par with members
of the family and community through psychosocial rehabilitation services
being rendered to the persons with severe mental illness.
2. Values

A rehabilitation professional actively involved in psychosocial rehabilitation follows


66 certain values which facilitate achievement of goals in integrating the person with
severe mental illness in the family and in ensuring her or his better quality of life. Mental Illness and
Psychosocial
These values are: Rehabilitation

i) Self determination,

ii) Dignity and worth of every individual,

iii) Capacity of every individual to learn and grow, and

iv) Culture sensitivity.

3. Guiding Principles

Following are the important guiding principles of psychosocial rehabilitation:

i) Individualisation of services: Psychosocial rehabilitation services should


be planned to suit individual needs of the person suffering from severe mental
illness according to his or her demographic characteristics (like age, gender,
education, locale, socioeconomic status and cultural background), nature of
illness and functional level in day to day work. Individual programme planning
of psychosocial rehabilitation services for two persons with same diagnosis
may differ in their individual rehabilitation needs of psychosocial rehabilitation
services.

ii) Maximum involvement and due importance to be given to preferences


and choices of person with severe mental illness: In order to ensure
maximum involvement, due importance should be given to choices and
preferences of person with severe mental illness. Anything cannot be imposed
on her or him in the name of psychosocial rehabilitation services.

iii) Normalised and community based services: Scope for community based
psychosocial rehabilitation services is wider, as this is known to be the door
step service delivery with an intention to reach the unreached. Such services
are not only in demand; rather, are known to be the need of the day,
especially for greater reach in the rural areas for wider coverage of severely
mentally ill population.

iv) Strength focus: Severity of mental illness is likely to cause many losses.
What has been lost due to severe mental illness should not be the primary
concern. Remaining positive potentials in terms of cognition, emotion, motor
activity level and social interaction of person with severe mental illness should
be the focus of overall rehabilitation process.

v) Situational assessment: Remaining positive potential has a situational


dimension. Psychosocial milieu of the person (like family setup, work place,
person’s social living conditions etc.) may also need to be thoroughly
understood to ensure favourable situational support.

vi) Treatment, rehabilitation, and integration through holistic approach:


Treatment, rehabilitation and integration into the community are linked; being
integral part of each other. They should not be dealt with in isolation.
Psychosocial rehabilitation for the management of severe mental illness should
be a holistic approach.
67
Persons with Disabilities
vii) Ongoing, accessible, and coordinated services: Psychosocial
rehabilitation services should be coordinated in such a manner that they are
not disrupted in between. They should be available with easy access as per
the requirements of the persons with severe mental illness as continued care.

viii) Training of skills and vocational focus: Severe mental illness undermines
the individual’s behaviour, performance, cognition and social interaction.
Certain skill deficits are apparent in the major categories of severe mental
illnesses. They are the focus of intervention in psychosocial rehabilitation.
There is continuum of skill training in the process of rehabilitation, that is
activities of daily living skills, social skills and lastly followed by vocational
skills. Through acquisition of these skills vocational focus should be kept in
mind to place the person in a remunerative job. This generates a feeling in
the individual that she or he is also a productive member of the society.

ix) Environmental modification support: At times modification in the


environment facilitates the process of rehabilitation. Provision of support
to such environmental modification should be available so that the same
is flexibly used.

x) Partnership with the family: The person with severe mental illness in
the family is not the only sufferer; rather, the whole family is greatly
affected due to severity of illness. This adds to the burden of caring on
regular basis. Hence, the family needs to be involved as part of the
process of psychosocial rehabilitation.

xi) Evaluative assessment with outcome oriented focus: Evaluation of


progress to ascertain the outcome of efforts of rehabilitation is necessary.
Usually progress is disrupted due to relapse, which also makes evaluative
assessment of outcome essential.
Check Your Progress Exercise 2
Note: a) Read the following questions carefully and answer in the space
provided below.
b) Check your answers with those provided at the end of this Unit.
1. What are the goals of psychosocial rehabilitation?
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
2. List the guiding principles of psychosocial rehabilitation.
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
68
Mental Illness and
18.4 HISTORICAL PERSPECTIVE Psychosocial
Rehabilitation
Curative efforts have usually remained the focus of country’s mental health services
in the post independence era, although scanty efforts have been made in another
priority area of psychosocial rehabilitation of severely mentally ill.
Early mental health services were centered around the mental hospitals of the
country, which have gone through various (nearly 4 to 5) phases of development
(Sharma & Chadda,1996). Clinical management of cases was primary concern
of these hospitals. Experiences are suggestive of the fact that a person suffering
from mental illness is not brought to the mental hospitals until and unless her or
his problems become dramatic and unmanageable. Thus, admission to a mental
hospital was considered to be forced choice as a last resort. Due to stigma
attached to mental illnesses prior to this admission, family used to make all possible
efforts to manage the problem of mentally ill member with the help of local faith
healers and doctors. Further, stigma plays significant role to the extent that in
majority of mental hospitals it was observed that clients continued to stay even
after recovery due to unacceptance by their families. This resulted in reduced
availability of active treatment beds (Sharma & Chaddha, 1996).
An analysis of psychosocial characteristics of indoor cases under treatment
in a leading psychiatric hospital of the country indicated that 60 per cent
beds (269 out of total 450) were occupied by long stay clients suffering from
chronic mental illness for more than two years. This analysis further concluded
that nearly 54 per cent of total hospital strength required only opportunities for
social learning and rehabilitation programmes (Gupta et al. 1996). Thus, out of
nearly 20,000 beds available in 37 state run hospitals of the country, 50 per cent
remain occupied by long stay clients (Gopinath, 2002). This shows that clinical
management of clients, was major concern of mental hospitals. Apart from clinical
management of clients some hospitals introduced activities to involve them in
work related to recreation oriented activities, ward cleanliness, assisting as helper
in kitchen in the name of rehabilitation (Gopinath, 2002). Hence, psychosocial
rehabilitation is said to be non-existent (Gopinath, 2002) or still in infancy stage
in India (Gopinath & Rao, 1994).
History of psychosocial rehabilitation can be traced back to community mental
health movement (1950s) in the West, which strongly emphasised de-
institutionalisation of clients in late 1950s and 1960s. It was done to promote
community based management and encourage after care programmes, to facilitate
clients to function optimally in the community.
Some positive efforts of this nature were also reported at that time in India which
is not known only as anticipating factor of the present day existing psychosocial
rehabilitation services of the country, rather said to be a landmark in this direction.
In 1950s Professor Vidya Sagar involved family members in the treatment of
mentally ill persons in 900 bedded hospital (Sharda Menon, 1996; Kapur, 2000).
This helped in :
i) Reducing hostility of the clients against their families,
ii) Making day to day improvement distinctly visible to the relatives and
iii) Reducing stigma (Kapur, 2000) attached to mental illness during those days.
69
Persons with Disabilities
Efforts of Dr. Vidyasagar, a psychiatrist from Rohtak, were able to prove that
treatment of mental illness using drugs only is inadequate. Other psychosocial
approaches, are also needed to manage. These approaches will enable a person
who is suffering from chronic mental illness, to function optimally and to live in the
community successfully. Final phase of development of mental hosiptals in the
country as reported by Sharma & Chaddha (1996) was seen in the post
independence era (1974 onwards). By this time emphasis of Government of India
(GOI) shifted from mental hospitals to creation of psychiatric departments in
general hospitals and medical schools.

The growth and development of these general hospitals’ psychiatric units (GHPU)
brought a significant change in the mental health services of the country. This was
referred to as a major revolution in the whole approach to psychiatric treatment
(Wing, 1978). There was a greater acceptability of these units as a method of
mental health delivery system. This also facilitated to a greater extent training of
mental health professionals and research work. Thus, even during this phase of
development of mental health services psychosocial rehabilitation was not focused
sufficiently. However, a number of advantages of GHPU over traditional mental
hospitals were able to prepare a foreground for the development of psychosocial
rehabilitation services of the country. Some of the stated advantages of these
services are listed below:

a) General hospital psychiatric units (GHPU) are situated right in the community
hence, they are easily accessible and approachable,

b) Family and relatives can visit the client and a relative or family member can
stay with patient,

c) Stigma of mental hospitals nonexistent,

d) No legal restrictions of admission or treatment, and

e) Availability of other medical facilities in the same set up.

Reduced stigma, easy accessibility of experts and the clinics, and the provision to
stay with disturbed client were some of the encouraging advantages that promoted
psychosocial rehabilitation of the people in the family and community.

Another important landmark after emergence of GHPU was the community


psychiatry movement in India, which began in early seventies. Main objectives
of this movement were to incorporate mental health care into primary health care
system. This programme was certainly able to take treatment into the community
and this also brought into focus the need for psychosocial rehabilitation of the
clients living in the community.

Subsequently, a well formulated National Mental Health Programme (GOI, 1982)


could not be implemented at that time due to number of reasons (Srinivasamurthy,
1989). According to Gopinath & Rao (1994), at the governmental level, policy
makers have not been able to devote serious attention to the development of
rehabilitation services for the chronic mentally ill primarily due to economic
constraints. However, mental health professionals, themselves, have to some extent,
been complacent.
70
Mental Illness and
18.5 MAGNITUDE OF THE PROBLEM Psychosocial
Rehabilitation

Marked increase in the number of persons suffering from chronic mental illness
has drawn the attention of professionals and State to cater to the needs of this
population. “Our forgotten millions” is the apt remark (Agarwal, 1998), which
signifies that we have paid inadequate attention to people suffering from mental
illness. Professionals feel that this population has remained a neglected lot and
now active action oriented efforts are needed to manage and rehabilitate this
neglected population (Kulhara, 1997).
According to Kulhara (1997), nearly 3,00,000 and 1,05,000 cases of schizophrenia
are added in a year in rural and urban population of the country, respectively. Out
of these 40 to 60 per cent cases go through the phase of chronicity and suffer
impairments and disabilities. These figures suggest that roughly 1,50,000 or more
people suffering from schizophrenia are added every year to country pool of
disabled schizophrenic population. A meta analysis of 13 epidemiological studies
reported a prevalence rate of 2.7 per cent for schizophrenic and 12.3 per cent
for affective disorder (Reddy and Chandrashekhar, 1999) which signifies urgent
need to develop rehabilitation services for people suffering from chronic mental
illness. Some earlier studies reported prevalence of schizophhrenia from 2 to 3
per 1000 all over the world. Indian researchers have also reported prevalence
rate ranging from 0.9 to 4.3 per 1000 (Sethi et al, 1967; 1972; Dube, 1970;
Elnagar, 1971; Nandi et al. 1975). Rajkumar (1995) noted incidence of
schizophrenia as 3 per 10,000 in urban areas. Above figures give an estimate that
there will be approximately 2 million persons suffering from schizophrenia in the
country at any given point of time.
Another disabling condition, affective disorders are now conceptualised as chronic
illnesses and the earlier notion of a better prognosis is being replaced with the
acceptance of the fact that very few patients of affective disorders have a single
episode and majority have a chronic course (Stephens, 1978).
Overall reported prevalence and incidence figures suggest immediate need for
psychosocial rehabilitation both in urban and rural areas with a nationwide service
network to help people in the community suffering from chronic mental illness.
Check Your Progress Exercise 3
Note: a) Read the following questions carefully and answer in the space
provided below.
b) Check your answers with those provided at the end of this Unit.
1. State ‘True’ or ‘False’ :
i) Dr. Vidyasagar proved that treatment of ....................
mental illness using drugs only is inadequate.
ii) Dr. Vidyasagar restricted family ....................
involvement in the treatment of mentally
ill persons.
iii) The general hospitals’ psychiatric units ....................
are easily accessible and approachable.
iv) Affective disorders are now conceptualised ....................
as chronic illness.
71
Persons with Disabilities
18.6 PRESENT SCENARIO
Looking into the three areas, that are service, availability of manpower and
research, it is evident that this significant area of mental health service, that is
psychosocial rehabilitation has just been touched upon and many priority areas
are still unexplored, in the Indian context.
In the Western countries, extensive efforts have been made to integrate persons
suffering from chronic psychiatric illness into the mainstream of society.
This includes drug compliance or medicinal management training, training
in activities of daily living, social skill training and vocational rehabilitation.
Another important development in the West is community mental health
movement in the 1950s, which is usually known to be the origin of
rehabilitation in psychiatry. Prior to 1950s care of chronically mentally ill
was primarily institution based and custodial in approach. Much has been
written about the long term deleterious effects of such care (Wing and Brown,
1970). This led to the “de-institutionalisation” of patients in the late 1950s and
early 1960s. There was a growing realisation that people with major mental illness
should be helped to maintain themselves in community and pharmacotherapy
alone is inadequate for their management. A comprehensive system of care,
encompassing a variety of therapeutic approaches is needed to enable chronically
mentally ill persons to function optimally in the community.
In India, psychosocial rehabilitation is still a new area of mental health services.
This has also remained a neglected area of Indian researchers. This is due to
availability of only a few rehabilitation centres (like daycare centres, halfway
homes etc.) in the country and greater reliance on medical model of treatment.
In a traditional Indian setup, unlike most of the Western societies, approximately
90 to 95 per cent of all chronically mentally ill are looked after by the family
(Agarwal, 1998). India still lingers on to be an orthodox and traditional country
in terms of family structure, ties and cohesiveness. Almost all our patients of
chronic mental illness still live in family set up. Very few are in institutions for
custodial care. Therefore, family is primarily the coping agency and significant
adults in the family (for example, parents and spouse) are the primary caregivers.
It has been shown that Indian families are accepting, less critical and hostile, and
more involved than the families of patients of chronic mental illness in the West.
However, despite this there is strong evidence that the presence of chronic mentally
ill patient causes or results in considerable amount of burden to the family. The
burden of care of patients of chronic mental illness is mainly felt in the areas of
family finance (for example, the cost of treatment, cost of transport, follow-up
visits, loss of earning, and loss of earnings of the caregiver due to the task of
looking after patient), routine family activities and family leisure.
With increasing urbanisation, life style is undergoing rapid change. The nuclear
family system and shrinking social networks combined with increasing
financial strain is making it more difficult to care for an ill relative. Studies
have documented that distress and burden of caring for an ill relative are high
(Gopinath and Chaturvedi, 1992; Sam et al., 1998) and disruptive of daily
routine (Rao et al., 1998). This is true for both rural and urban families (Mubarak
Ali and Bhatti, 1988 ; Singh et. al. 2010; Chadda et. al., 2007).
72
Mental Illness and
Aftercare services in the form of daycare centres, halfway homes or rehabilitation Psychosocial
programmes are almost nonexistent in India, though an initiation in the field has Rehabilitation
taken place in some cities like Bangalore, Delhi, Ranchi and Madras (Pai &
Kapoor, 1983; Gopinath & Rao, 1994).

In India, formulation of precise functional definition and quantification of


psychiatric disability is still in the process. Some of the facts regarding the status
of chronically mentally ill in India are as follows (Agarwal, 1998) :

 Roughly 0.5 to 15 per cent population will have certain disability, due to
chronic mental illness,

 Barring a few thousand all others are living in the community,


 They are occupationally impaired. Their family and personal life is in shambles,
 Most of these patients are either maltreated or untreated,
 There are roughly 35,000 psychiatrists and most of them are concentrated
in large towns or in big institutions. Most non-governmental psychiatrists
are working single-handed, ignoring multi-disciplinary approach,
 Almost all major towns have one to two psychiatrists yet many cities
remain uncovered,
 Only few hundred non-medical mental health professionals are available
which includes clinical psychologists, psychiatric social workers and
psychiatric nurses,
 There are roughly 35,000 hospital beds most of which are poorly managed
and are often occupied by chronically ill,
 Treatment being completely voluntary, most patients seek treatment on
outpatient basis and discontinue treatment when active symptoms are
controlled or when they do not get adequate response or due to disabling
side effects of drugs,
 Most psychiatrists depend on pharmacotherapy. Attempts at psychoeducation
and rehabilitation are generally limited to occassional verbal advice,
 Many become homeless or live in their own house but uncared and their
properties are misappropriated by their relatives,
 However, there are few centres of excellence doing commendable work in
developing research data and models for treatment, and
 Most of these groups are active in few cities of India.
Factors which contribute to the prolonged (severe or chronic) nature of mental
illness in the Indian context are worth considering, as they are closely related to
the current practice of psychosocial rehabilitation in India. Let us discuss some of
these factors:
1. Misconception and stigma: Misconception about mental illness and related
stigma usually leads to delay in diagnosis and inadequate treatment. Although
attitudes of the people have changed but still larger population of the country
both in urban and rural areas are not aware of the importance of early 73
Persons with Disabilities
identification, diagnosis and treatment. Religio-philosophical thinking of people
adds to the problem and makes it more severe and thus, delay in early
treatment results in severity or chronicity of illness.
2. Limited facilities of clinical care: Considering the larger population of the
country, treatment facilities still seem to be inadequate, especially in the rural
areas, as most of these clinical services are available in the cities.
3. Cost of treatment: Many a times it has been observed that drug compliance
is poor among the persons with severe mental illness of lower middle and
lower socio-economic groups. Drug compliance is a significant part of
psychosocial management. Due to economical reasons a good number of
cases are unable to comply with the prescribed medication, which has to be
taken regularly that also in most of the cases on long term basis or lifelong.

4. Medicine’s side effects: Medication causes side effects and due to these
effects treatment is discontinued when the side effect is severe or when
most of symptoms are managed. Whereas, prescribed continued
medication is very necessary to avoid relapse.

5. Negative symptoms: Negative symptoms are difficult to treat and their


persistence also contributes to severity or chronicity of these illnesses.

Some other associated problems responsible for severity/chronicity are


physical illnesses in addition to mental health problems, unemployment and
poverty, no shelter and lack of family and social support.
Check Your Progress Exercise 4
Note: a) Read the following question carefully and answer in the space
provided below.
b) Check your answer with that provided at the end of this Unit.
1. List the factors which contribute to the prolonged mental illness in Indian
context.
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................

18.7 STRATEGIES OF MANAGEMENT IN


PSYCHOSOCIAL REHABILITATION
In this section, we will discuss some strategies which are important in the
management in psychosocial rehabilitation.
1. Pharmacotherapy
Last few decades have very clearly demonstrated the effectiveness of
74 pharmacological treatment for both affective disorders and schizophrenia.
Two points, which have been emphasised in most of the clinical reports are: Mental Illness and
Psychosocial
i) Early and prompt drug treatment can reduce chronicity, and Rehabilitation
ii) Continuous treatment (drug compliance) is required for most relapsing
clients and the treatment may be required lifelong.
2. Psychosocial Management
The psychosocial management includes following strategies:
i) Developing and applying measures to assess the effectiveness of
medication: When drugs are used to treat symptoms or psychopathology,
the primary criterion for their success is behaviour change in the patient.
Psychologists among the professionals (of mental health treatment team) are
supposed to assess such behavioural changes. Intervention to increase
medication compliance using behaviour management techniques, particularly
with discharged client has been noted to be useful. Behavioural techniques
are used to reduce the unpleasant side effects of medications as well.
ii) Intervention with cognitive techniques directly to remedy cognitive
and behavioural deficits: Mental health professionals especially
psychologists can use self instructional training to help patients with
schizophrenia to function more appropriately in social situations, or to examine
treatment related cognitions to increase medication compliance. To combat
hopelessness and to disrupt negative self fulfilling prophecies use of cognitive
intervention also helps, which increases clients’ expectations of success.
Psychosocial intervention enhances the efficacy of treatment.
iii) Developing and applying measures to assess both the stress
experienced by individuals and availability of the internal and external
resources available to cope with the stress: Intervening to reduce stress
in the lives of vulnerable individuals, also reduces the risk of mental illness
and thus also prevents re-hospitalisation. This is done by teaching stress
management (for example, to identify stressors, manage stress, and solve
problems), environmental management skills, and the social skills necessary
to build their social networks. Although vulnerable individuals are thought to
have lower thresholds for stress, social support has been shown to buffer
stress and reduces vulnerability to both physical and mental illness. Clients
and family members need to know and recognise the early signs of impending
illness and develop strategies to reduce its likelihood, with the help of mental
health professionals.
iv) Intervening to correct the deficits observed through functional
assessment: Behavioural and skills training approaches can increase the
client’s role functioning and help them develop support systems in the
environment (Wallace et al., 1980).
Advocacy is said to be very important in this approach (Anthony and
Libermen, 1986). Negative attitudes of community towards persons with
mental illness unfortunately are often also shared by mental health professionals
(Lefley, 1989). To promote positive attitudes towards persons with chronic
mental illness, involvement of mental health professionals in community
education, professional education and in the administration of programmes
concerned with chronically mentally ill persons has been reported to be
75
beneficial.
Persons with Disabilities
v) Intervention to provide information about the nature, etiology, and
treatment of mental illness to the family members (Psychoeducation):
Family members’ skills which help them to become more effective caregivers
and cope more effectively with the bizarre behaviours of the ill patients
(Fallon et al.,1985) depend on information passed to them by a mental
health professional. By reducing the amount of expressed emotion (defined
as critical comments directed towards the patient and over involvement in the
patient’s affairs) in the family environment, caregivers reduce the risk of
client’s relapse (Leff, Kuipers, Berkowitz, Eberlein-Vreis and Sturgeon, 1982).
Finally, consistent professional support to the patients and their family members
by teaching them skills for coping with stress and for expanding their social
networks (Anderson et al., 1986; Fallon et al., 1985) facilitates the
rehabilitation process and reduces the burden of caregiving. Family therapy
helps the family to cope with the grief, guilt and anger of having a mentally
ill family member and deal with any other problems that may make caregiving
more difficult.
The Role of Psychosocial Rehabilitation in the Management of Chronically
Mentally Ill Person: There cannot be a better explanation of the course of
successful management than a client’s account describing importance of
psychosocial rehabilitation which distinctly illustrates role of drug compliance,
family support and socio-cultural factors. According to a client’s account (First
person’s account, 1996; Schizophrenia Bulletin 22, 1, 183 & 85):
“Overcoming schizophrenia was not easy. Taking my medications faithfully
is the most important element in keeping me out of the hospital……
…….A loving and close relationship with my parents has also helped
me to overcome my illness…..
……one factor that enabled me to get beyond the social effects of my
illness, was religion.
A group of recovered clients identified helpful factors in overcoming the disabling
effects of their chronic mental illness (Lee et al., 1993). These are listed in Table
18.2.
Table 18.2 Helpful factors in overcoming the disabling effects of chronic mental
illness

S.No. Rank order of identified helpful factors Percent (%)


1. Psychotropic medication 71
2. Cognitive coping efforts 42
3. Social support and guidance 28
4. Better organisation of occupation and time 28
5. Work 13
6. Stress reduction 10
7. Efforts of self improvement 9
8. Positive life events 8
76
Psychosocial rehabilitation is the cardinal feature in the management of chronic Mental Illness and
Psychosocial
mental illness. Major concern is “how can we help people (who may not get Rehabilitation
better) despite their disability?” which conveys that “by all means try and treat
people but if they do not respond then how can we help them make the best
adaptation possible, given the fact that they have difficultes in functioning which
are in the current state of knowledge, essentially untreatable?”

18.8 LEGAL ASPECTS, ADVOCACY AND


COMMUNITY PARTICIPATION
In this section, we will discuss the legal aspects of rehabilitation and importance
of advocacy and community participation. Legal aspects of rehabilitation relate to
quantification of disability arising out of mental illness.
This enables the victim of severe mental illness to avail concessions, facilities and
benefits made available by the government. Psychiatric disability has already been
included in Person with Disabilities Act (1995). To assess degree of disability,
‘Indian Disability Assessment scale’ (IDEA:GOI, 2004) is now being used in
most of the mental health service centres and psychiatry departments of the
hospitals. A disability of 40 per cent and above entitles a person to avail the
benefits.
Although family care is the best care for rehabilitation; a range of supported
service options have been developed but they are available in cities only with
limited numbers.
Halfway Homes
A person with severe mental illness goes to these homes during working hours
where counseling services, skill training projects and facilities for vocational training
are available. As per one’s rehabilitation needs services are provided under
supervision. Residents are encouraged to participate in these activities. In the
evening persons with mental illness come back to their families.
Long Term Group Residences
Cases with long term severe disability are provided support and supervision.
These are known to be long stay clinical units. Basically in cases for whom
expectations are low and benefits of rehabilitation are minimal these units are
setup usually in hospitals.
Stigma about mental illness is still prevalent in the community which requires
generation of awareness to change attitudes of people. This kind of change will
promote early detection and early intervention which prevents severity or chronicity
of mental illness. Many cases go untreated or right treatment at appropriate place
is not availed which retards the treatment process and further process of
rehabilitation.

18.9 ROLE OF COUNSELLOR AND FAMILY


THERAPIST
Let us discuss the importance of role of counsellor and family therapist in
psychosocial rehabilitation and learn about the different types of roles the counsellor
and family therapist plays in psychosocial rehabilitation. These roles are as follows: 77
Persons with Disabilities
1. Listen to the person carefully: Allow the person with severe mental illness
to express her or his emotions, feelings, and opinions and listen carefully and
try to ascertain role of hope in her or his life and resources available with
her or him that is, personal resources (like cognitive: attention, intelligence,
memory; her or his emotion and activity level), and familial resources (like
family support, financial status of the family to support treatment and
rehabilitation).

2. Psychoeducation: Explain the facts about the illness to victim and her or his
family members. Many a times person with severe mental illness may not be
able to comprehend; then educating family members about the nature, etiology,
course of treatment and prognosis to family members becomes vital. Cost of
treatment and need of continued care need to be explained to family.

Expressed emotions in the family are reported to be many a times reason of


relapse. Family members should be informed to avoid any direct critical
comments to the affected family members or any negative comment about
her or his illness.

Clearly state the importance of compliance to medication, its side effects and
negative consequences of noncompliance to medication.

3. Allow freedom to choose: Provide information to the person with severe


mental illness and her or his family about various treatment options available
for her or his condition and allow them to choose.

4. Maintain confidentiality: Information gathered from the person with severe


mental illness should be used for treatment and rehabilitation purposes
exclusively and should not be shared with anyone.

5. Provide desired information: Families want to know about availability of


service facilities, concessions, facilities and benefits available to the severelly
mentally ill as per provisions of the government.

6. Respect the person with severe mental illness and her or his human
rights: All such persons are human beings and services provided to them
should be in conformity with basic human rights. Physical punishments,
unnecessary restraint, confining them in solitary cells are unethical. The tragic
Yerwadi incident (2001) where 25 inmates of a treatment centre were burnt
alive as they were chained led to passing legislation for regular inspection of
hospitals to ensure that human rights of persons with severe mental illness in
these hospitals are not violated.

7. Conduct counselling and family therapy sessions to resolve specific


issues: Sometimes specific issues which emerge during the rehabilitation
process like family support, interpersonal processes in the family, marital
relations etc. should be addressed and resolved. Accordingly, counsellors or
family therapists need to conduct counselling sessions with the person with
mental illness and her or his family members to resolve such issues.

78
Mental Illness and
Check Your Progress Exercise 5 Psychosocial
Rehabilitation
Note: a) Read the following questions carefully and answer in the space
provided below.
b) Check your answers with those provided at the end of this Unit.
1. What are the strategies of management in psychosocial rehabilitation?
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
2. Outline the role of counsellor and family therapist in psychosocial
rehabilitation.
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................

18.10 LET US SUM UP


Major mental illnesses including schizophrenia and bipolar affective disorder are
severe in nature. Their prolonged duration, if not treated properly in the initial
stage are likely to cause disability. To manage this disability, psychosocial
rehabilitation is important. Strategies applicable in this process are ensuring
compliance to medication, psychoeducation to the person with severe mental
illness and her or his family, remediation of cognitive and behavioural deficits, skill
training (activities of daily living, social and vocational) and integration into the
family and society. There are related issues like confidentiality of information,
conformity to human rights, which should be kept in mind while extending counselling
services.

18.11 GLOSSARY
Expressed emotion : Critical comments directed towards the
patients and over involvement in the patient’s
affairs.
GOI : Government of India.
GHPU : General Hospital’s Psychiatric Unit
Intrinsic factors : Primary factors
Psychiatric disability : Disability arising out of severe mental illness
Psychosocial rehabilitation : Process that facilitates the opportunity for
disabled or handicapped by a mental
disorder to reach their optimal level of
independent functioning.

79
Persons with Disabilities
18.12 ANSWERS TO CHECK YOUR PROGRESS
EXERCISES
Check Your Progress Exercise 1
1) i) Bipolar affective disorder
ii) Phase of mania
iii) intervening
2) Following are the four key areas of psychiatric disability:

i) Activities of daily living skills (for example, grooming, hygiene, maintaining


a household, managing finances),
ii) Social functioning (for example with family, friends, community, and in
the workplace),
iii) Concentration, pace and task persistence (ability to function for 6 to 8
hours without supervision), and
iv) The ability to tolerate competitive work.
Check Your Progress Exercise 2
1. The major goals of psychosocial rehabilitation are given below:

i) Recovery from mental illness,


ii) Integration in the family and community; and
iii) Better quality of life.
2. Following are the guiding principles of psychosocial rehabilitation:
i) Individualisation of services,

ii) Maximum involvement and due importance to be given to preferences


and choices of person with severe mental illness,

iii) Normalised and community based services,

iv) Strength focus,

v) Situational assessment,

vi) Treatment, rehabilitation and integration through holistic approach,

vii) Ongoing, accessible and coordinated services,

viii) Training of skills and vocational focus,

ix) Environmental modification support,

x) Partnership with the family, and

xi) Evaluation assessment with outcome oriented focus.


80
Check Your Progress Exercise 3 Mental Illness and
Psychosocial
i) True Rehabilitation

ii) False
iii) True
iv) True
Check Your Progress Exercise 4
1. Following are the factors which contribute to the prolonged mental illness in
Indian context:
i) Misconception and stigma,
ii) Limited facilities of clinical care,
iii) Cost of treatment,
iv) Medicine’s side effects, and
v) Negative symptoms.
Check Your Progress Exercise 5
1. Following are the main strategies of management in psychosocial rehabilitation:
i) Developing and applying measures to assess the effectiveness of
medication,
ii) Intervention with cognitive techniques directly to remedy cognitive
and behavioural deficits,
iii) Developing and applying measures to assess both the stress experienced
by the individual and availabity of internal and external resources to
cope with stress,
iv) Intervening to correct the deficits observed through functional assessment,
and
v) Intervention to provide information about the nature, etiology, and
treatment of mental illness to the family members.
2. Thes role of counsellor and family therepist in psychosocial rehabilitation
involves the following:
i) Listening to the person carefully,
ii) Psychoeducation,
iii) Allowing freedom to choose,
iv) Maintaining confidentiality,
v) Providing desired information,
vi) Respecting the person with severe mental illness and her or his human
rights, and
vii) Conducting counselling and family therepy sessions to resolve specific
issue.
81
Persons with Disabilities
18.13 UNIT END QUESTIONS
1. Name two major mental illnesses causing disability and list their clinical
characteristics.

2. What is psychosocial rehabilitation?

3. List strategies used in the management of psychiatric disability.

4. Describe the role of counsellor and family therapist in psychosocial


rehabilitation of persons with severe mental illness.

18.14 FURTHER READINGS AND REFERENCES


Agrawal, A.K. (1998). The forgotten millions. Indian Journal of Psychiatry, 40,
103-19.

Chadda R.K., Pradhan, S.C., Bapna, J.S. & Singhal, R. (2000): Treatment needs
of chronic psychiatric patients. Journal of mental health and human behaviour,
5, 1, 13-18.

Chadda, R.K., Pradhan, S.C., Bapna, J.S., Singhal, R. & Singh, T.B. (2000).
Chronic psychiatric patients: An assessment of treatment and rehabilitation related
needs. International Journal of Rehabilitation Research, 23, 55-58.

Chadda, R. K., Singh, T.B. & Ganguly, K.K. (2007). Caregivers burden and
coping: A prospective study of relationship between burden and coping in caregivers
of patients with schizophrenia and biopolar affective disorder. Social Psychiatry
and Psychiatry Epidemiology, 42, 4,923-930.

Dilk, M.N.& Bond, G.R.(1996). Meta-analytic evaluation of skills training research


for individuals with severe mental illness. Journal of Consulting and Clinical
Psychology, 64, 6, 1337- 1346.

Dick, P.H. (1990). Psychiatric inpatient rehabilitation: Is there a future. International


Journal of Rehabilitation Research, 13, 2, 119-126.

Dubey, K.C. (1970). A study of prevalence and biosocial variables in mental


illness in a rural and urban community of Uttar Pradesh, India. Acta Psychiatrica
Scandinavia, 86,499-503.

Elnager, .M.N., Maitra R. & Rao. M.N. (1971). Mental Health in an Indian rural
community. British Journal of Psychiatry, 118, 499-503.

Gopinath, P.S. & Chaturvedi, S.K. (1992). Distressing behaviour of schizophrenics


at home. Acta Psychiatrica Scandinavia, 86, 185-188.

George R.M., Chaturvedi S.K., Murali T.,Gopinath P.S. & Rao S.L.(1996).
Cognitive deficits in relation to quality of life in chronic schizophrenics. NIMHANS
Journal, 14,1,1-5.

Gupta, P., Prabhu, M. & Prabhu, G.G. (1969). Rehabilitation of the chronic
psychiatric patients. Indian Journal of Psychiatry, 10, 157-165.

82
Jones, B.N., Jayram, G., Samuels, J. & Robinson, H. ( 1998). Relating competency Mental Illness and
Psychosocial
status to functional status at discharge in patients with chronic mental illness. Rehabilitation
Journal of American Academy of Psychiatry and Law, 26, 1, 49-55.
Kapur, R.L.(1992). The family and schizophrenia : Priority areas for intervention
research in India. Indian Journal of Psychiatry, 35, 1,3-7.
Kulhara, P. (1997). Schizophrenia –the neglected lot: Call for action. Journal of
Mental Health and Human Behaviour, 2, 1, 3-7.
Liberman R.P., Wallace, C.J., Blackwell, G., Kipeliwicz A., Vaccaro, J.V. &
Mintz, J. (1998). Skill training versus psychosocial occupational therapy for persons
with persistent schizophrenia. American Journal of Psychiatry, 155,8, 1087-1091.
Nandi , D.N., Ajmany, S., Ganguli, H . , Banerjee , G., Boral ,G.C. ,Ghosh, A.&
Sarkar ,S. (1975): Psychiatric disorders in a rural community in West Bengal: An
epidemiological study. Indian Journal of Psychiatry, 17, 87 -99.
Padmawati, R., Thara, R. Sriniwasan, L. & Kumar, S. (1995). SCARF Social
functioning index. Indian Journal of Psychiatry, 37, 4, 161-164.
Pradhan, S.C., Sinha, V.K. & Singh, T.B.(1999). Psychosocial dysfunctions in
patients after recovery from mania and depression. International Journal of
Rehabilitation Research, 22, 303-309.
Roder, V., Zorn, P., Miller, D., & Brener, H.D.(2001). Improving recreational,
residential and vocational outcomes for patients with schizophrenia. Psychiatric
Services, 52, 11, 1439-1441.
Roy Choudhary, J., Mondal, D., Boral, A. & Bhattachrya, D. (1995). Family
burden among long term psychiatric patients. Indian Journal of Psychiatry, 37,
2, 81-85.
Sartorious, N., Jablensky, A., Earmberg, G., Korten, A. , Anker, M., Cooper,
J.E. & Day, R.(1996). Early manifestation of first contact incidence of schizophrenia
in different cultures. Psychological Medicine, 16, 909-928.
Menon, S.M. (1996). Psycho-social rehabilitation: current trends. NIMHANS
Journal, 14, 4, 295-305.
Stephens, J.H.(1978). Long term prognosis and follow up. Schizophrenia Bulletin,
1, 4, 25-47.
Sethi, B.B. & Gupta, S. C. (1972). An analysis of 2000 private and hospital
psychiatric patients. Indian Journal of Psychiatry, 14, 197-206.
Suman, C., Baldev, S., Sriniwasmurthy, R. & Wig, N.N. (1980). Helping the
chronic schizophrenic and their families in the community: Initial observations.
Indian Journal of Psychiatry, 22, 97-102.
Thara, R.,l Rajkumar, S. & Valecha, V. (1988). Schedule for the assessment of
Psychiatric disability- A modification of the DAS-II. Indian Journal of Psychiatry,
30, 1, 97-102.
Thara, R.,Rajkumar, S., (1970). A study of sample attrition in follow up of
schizophrenia. Indian Journal of Psychiatry, 32, 3, 217-222.

83
Persons with Disabilities
Thara, R. & Rajkumar, S. (1993). Nature and course of disability in schizophrenia.
Indian Journal of Psychiatry, 35, 1, 33-35.
Thara, R. & Srinivasan, L. (1997). Marriage and gender in Schizophrenia. Indian
Journal of Psychiatry, 39, 1, 61-69.
Thara, R. & Srinivasan, L. (1998). Management of social disabilities in
schizophrenia. Indian Journal of Psychiatry, 40, 4, 331-337.
Trivedi, J.K. (1999). Quality of life in Psychiatric patients. Indian Journal
of Psychiatry, 41, 4, 277-279.
Wallace, C.J., Nelson, C.J..Liberman, R.P., Atchison, R.A., Luckoff, D., Elder,
J.P. & Ferris, C. (1980). A review and critique of social skills training with
schizophrenia patients. Schizophrenia Bulletin, 6, 42-63.
Walia, A.,Shivalkar, R., & Singh, T.B. (2006). Hospital based cross sectional
study of caregivers burden in chronic schizophrenia. M.Phil. Clinical
Psychology, Dissertation submitted to University of Delhi , Delhi.
Wig, N.N., Varma, V.K., Mattoo, S.K. ,Behre, P.B., Phookan, H.R., Misra
A.K., Sriniwasmurthy, R., Tripathi, B.M. , Menon, D.K. Khandelwal S.K. &
Bedi, H. (1993). An incidence study of schizophrenia in India. Indian Journal
of pf Psychiatry, 35,1, 11-17.

84
UNIT 19 PERSONS WITH
LOCOMOTOR DISABILITY
AND MULTIPLE
DISABILITIES
Structure
19.1 Introduction
19.2 Definition of Locomotor Disability
19.3 Causes of Locomotor Disability
19.4 Other Conditions that Lead to Disability
19.4.1 Spinal Cord Injury
19.4.2 Poliomyelitis
19.4.3 Cerebral Palsy
19.4.4 Epilepsy
19.4.5 Cerebrovascular Accidents
19.4.6 Arthritis
19.4.7 Muscular Dystrophy
19.4.8 Amputations
19.4.9 Club Foot
19.4.10 Leprosy
19.4.11 AIDS (Acquired Immuno Deficiency Syndrome)
19.4.12 Diabetic Neuropathy
19.4.13 Gout

19.5 Prevention of Locomotor Disability


19.6 Problems Faced by the Locomotor Disabled Person
19.7 Multiple Disabilities
19.7.1 Causes of Multiple Disabilities
19.7.2 Prevention
19.7.3 Intervention
19.8 Rehabilitation
19.9 Let Us Sum Up
19.10 Glossary
19.11 Answers to Check Your Progress Exercises
19.12 Unit End Questions
19.13 Further Readings and References

19.1 INTRODUCTION
An individual due to bodily impairment is unable to execute activities associated
with moving both her or his body and objects in the surroundings from one place 85
Persons with Disabilities
to another and from one position to another. This condition is known as locomotor
disability And, if an individual has impairment as a result of involvement of two
or more bodily functions such as deaf and dumb; deaf and blind; cerebral palsy
and mental retardation; etc, it is known as multiple disability.
In this Unit, we would study about the causes and characteristics of locomotor
disability and multiple disabilities.
Objectives
After studying this Unit, you will be able to:
 Define locomotor disability;
 Describe the causes of locomotor disability and multiple disabilities;
 Illustrate various types of locomotor disability and multiple disabilities; and
 Discuss the screening and intervention for them.

19.2 DEFINITION OF LOCOMOTOR


DISABILITY
Locomotor disability is defined as an individual’s inability to execute
distinctive activities associated with moving both oneself and objects from
one place to another. This inability could be a result of musculoskeletal and/
or nervous system.
Persons with Disabilities (Equal Opportunities, Protection of Rights and Full
Participation) Act, 1995, defines locomotor disability as “the disability of the
bones, joints or muscles leading to substantial restriction of the movement
of the limbs or any form of cerebral palsy”.

World Health Organisation (WHO) (1980) defined “locomotor disabilities” as an


individual’s inability to execute distinctive activities associated with moving, both
himself and objects from place to place.

National Sample Survey Organisation (NSSO) (1991) defined locomotor disability


as “the loss or lack of normal ability of an individual to move both herself or
himself and/or objects from one place to another”. It may occur due to 1)
paralysis of the limb or body; 2) deformity in the limb(s); 3) loss of limb(s); 4)
dysfunction of joints of the limb(s); and 5) deformity in the body other than limb
(for example, deformity in the spine or in the neck or dwarfing or sturting).

Check Your Progress Exercise 1


Note: a) Read the following question carefully and answer in the space
provided below.
b) Check your answer with that provided at the end of this Unit.
1) What do understand by the term locomotor disability?
................................................................................................................
................................................................................................................
................................................................................................................
86
Persons with Locomotor
19.3 CAUSES OF LOCOMOTOR DISABILITY Disability and Multiple
Disabilities

The various causes of locomotor disability are as follows:

1. Neuromuscular impairments: Neuromuscular impairment is a result of the


involvement of the muscles and the nerves in the body.

2. Musculoskeletal impairments: Musculoskeletal impairment is a result of


the involvement of the muscles and the bones of the body.

3. Congenital and developmental causes: Congenital and developmental


causes have an impact on the development of foetus inside the mother’s
womb. The various deformities that arise due to this cause are: cerebral
palsy; congenital tulips equinox virus (club foot or CTEV); congenital
dislocation of hip; phocomelias (means very short or flipper like limbs caused
by the intake of drug thalidomide during pregnancy) and, menigocele or
menigo-myelocele (an anomaly in which instead of nerves a sac is present
at the back of the brain containing cerebrospinal fluid).
4. Acquired causes : Acquired cause occurs due to external infections caused
by bacteria and virus that infect the body through the routes of air, water,
food, blood, saliva and semen. It could lead to tuberculosis of spine and
other joints; chronic osteomyelitis, septic arthritis, acute poliomyelitis; gulling
bare syndrome, leprosy, encephalitis; and AIDS.

5. Traumatic causes : Traffic accidents, domestic accidents, fall from height


or slip on the floor/road; bullet injury, war, riots, violence, sport injury,
natural clamities like earthquake, floods, etc. may lead to traumatic causes.

6. Vascular Causes : Vascular causes of locomotor disability are accidents


which affect cerebrovascular region, amputations caused due to peripheral
vascular disease and Perth’s disease.

7. Neoplastic causes : Neoplastic causes which lead to disability are brain


tumours, spinal tumours and osteosarcoma.

8. Metabolic causes : Metabolic causes like rickets, diabetic neuropathy,


Vitamin B-12 deficiency, and gout also lead to locomotor disability.

9. Degenerative causes : Degenerative causes refer to causes that begin at


birth and the condition deteriorates with the increase in age. These causes
could be motor neuron disease, Parkinson’s disease, multiple sclerosis,
osteoarthritis and spondoloysis.

10. Other miscellaneous causes : Locomotor disability may also be caused


by muscular dystrophy; lathyrism which is caused by eating Kesari dal that
looks similar to Arhar dal; rheumatoid arthritis and iatrogenic i.e. causes that
are unknown.

87
Persons with Disabilities
Check Your Progress Exercise 2
Note: a) Read the following question carefully and answer in the space
provided below.
b) Check your answer with that provided at the end of this Unit.
1) What is neuromuscular impairment?
.............................................................................................................
.............................................................................................................
.............................................................................................................
.............................................................................................................

19.4 OTHER CONDITIONS THAT LEAD TO


DISABILITY
In the above Section we have discussed about the various causes of disability.
There are some more conditions which also lead to locomotor disability. We
would discuss these in this section.

19.4.1 Spinal Cord Injury


Injury to the spinal cord is one of the major reasons that lead to locomotor
disability. Spinal cord injury is caused by traffic accidents, activity during
sports and recreation, fall from heights, penetrating wounds like bullet injuries,
diseases like bone tuberculosis, injury due to heavy weight lifting, etc.
From spinal cord, nerves go to all parts of the body. The person with spinal
cord injury would show the following signs and symptoms:
 Change in the tone of the limbs of which nerves are affected in the
spinal cord injury,
 Loss of sensation,
 Loss of sexual function,
 Loss of urinary and faecal control,
 Inability to use the affected limbs, and
 Development of pressure sores on the weight bearing parts of the body
like buttocks, heels, hips, back etc.
The injury to the spinal cord could be partial injury or complete injury. Injury to
spinal cord can also lead to paralysis of the body limbs. If the paralysis involves
the lower limbs then it is called paraplegia. If the paralysis involves all the four
limbs then it is called quadriplegia. And, if the paralysis is only half of the body
then it is called hemiplegia.

19.4.2 Poliomyelitis
Polio is a condition resulting as a consequence of a viral infection in the body. It
occurs in young children and the infection starts with a cold, fever and diarrhoea.
88
Polio is caused by various strains of virus namely, Leon, Lansing and Brunshilde Persons with Locomotor
Disability and Multiple
of which Lansing is the most virulent. It spreads through stool of the infected Disabilities
child who does not show apparent signs of polio but is a carrier of the virus.
Deformities in Polio:
 Scoliosis: In this condition the spine curves laterally. As a result it decreases
the space in the upper or the thoracic cavity as a result of which the space
for the heart and the lungs decreases.
 Over extended knee joint: This condition is called genu recurvatum. It is
caused because the weight of the body is borne by the weak leg and as a
result the knee of this weak leg gets bent backwards.
 Knee flexion contracture: In this condition the knee gets fixed in a bent
position if not corrected.
 High arched foot: It is also called pes cavus. It is caused when the bones
of the mid foot get bent. As the middle of the foot bends it gives the
appearance of the foot having a high arch.
Signs and Symptoms of Polio
The various signs and sysmptoms of polio are:
 It results in paralysis of the lower limbs and the limbs become flacid, very
loose and not stiff.
 The affected limbs become thin and also do not grow.
 The muscles of the affected limb become weak.
 Deformities and contractures may result due to paralysis of the limbs and
deformities of the limbs may also occur due to disuse of the limb or
inappropriate position in which the limb is held etc.
 Deformities that are seen in polio are scoliosis, over extended knee joint,
knee flexion, contracture, high arched foot etc.

19.4.3 Cerebral Palsy


Cerebral Palsy is a neuromotor disorder of movement which is non-progressive
and changes in its presentation. It is caused as a result of trauma to the developing
brain during the growth years.
Causes of Cerebral Palsy
Cerebral palsy can be caused during any period of time from prenatal period,
during birth or after the birth of the baby. Damage to the brain can occur during
difficult labour process or due to trauma to the brain during premature delivery
or due to use of forceps during the birth process. The foetus may also get infected
and if poor brain development takes place during pregnancy it can also cause
cerebral palsy. Cerebral palsy can be caused due to failure of the brain to develop
normally because of various reasons like genetic disorders, chromosomal
abnormalities or due to faulty blood supply to the brain. Infections like meningitis,
encephalitis, neonatal jaundice, accidents and trauma to the brain, severe
malnutrition, are other factors that may lead to cerebral palsy in children.
89
Persons with Disabilities
Thus, the brain can be neurologically damaged during the prenatal development,
during the birth process and even after the birth of the baby.
Risk Factors During Pregnancy
There are various factors during pregnancy which make the growing foetus
susceptible to cerebral palsy. These are:
 Mother suffering from hyperthyroidism, asthma, hypertension etc.,
 Pregnant woman being exposed to infections like rubella, typhoid, measles,
chickenpox etc.,
 Pregnant woman does not get adequate nutrition,
 Pregnant woman consumes drugs, alcohol,
 Pregnant woman suffering from seizures,
 Overexposure of the pregnant woman to radiation;
 Rh incompatibility among the parenting couple, and
 Expectant mother facing stress and trauma.
Risk Factors During the Birth Process
The risk factors during birth process are:
 Baby is delivered prematurely,
 Labour process is prolonged and infant undergoes trauma,
 Difficult delivery due to breech or transverse positioning of infant,
 Child is born with the umbilical cord around the neck making breathing
difficult causing anoxia,
 Delayed birth cry,
 Newborn is low birth weight due to under-nutrition,
 Neonate suffers convulsions, and
 Accidental injury to the neonate’s head due to forcep delivery.
Risk Factors After Birth
The various risk factors that may cause cerebral palsy after the birth of the child
are:
 Child suffers from infections such as meningitis and encephalitis in the
early years of life,
 Child suffers from seizures due to abnormal brain activity,
 Brain receiving insufficient blood supply due to breathing difficulty (asphyxia),
 There is bleeding in the interior surfaces of the brain,
 Presence of tumors in the brain,
 Presence of excessive fluid in the brain (hydrocephalus),
90
 Trauma caused to the brain by accidents and injuries, and Persons with Locomotor
Disability and Multiple
 Jaundice just after birth of the newborn. Disabilities

Screening
The newborn child can be screened for presence of cerebral palsy by
complimentary neuromotor examination which is different from the basic
neuromotor examination. It involves repeated assessments as well as
immediate therapy. Such an examination can help identify babies with transient
patterns of abnormality and also with persistent patterns of abnormality. This
helps to assess the condition of cerebral palsy in the growing child.
In cerebral palsy some of the infantile reflexes that are present in infants for some
period after birth, persist long after the ages when they should have been integrated
within the nervous system. Some of these reflexes that persist are moro reflex,
palmer reflex, tonic reflex, planter grasp etc. Children with cerebral palsy have
weak muscles of the trunk, head, shoulder, and pelvic girdle.
Clinical types of movement disorders in cerebral palsy are:
Spasticity – Spasticity is a type of muscle hypertonia featured as an abnormal
and increased response to rapid stretch, and movement occurs in disorganized
fashion. It implies increased tone in the limbs but decreased tone in neck and
trunk region. Spasticity is mainly in the anti-gravity muscles, that is, extending the
arm produces more resistance than flexing it.
Dystonia – Dystonia is the production of one type of muscle activity when
another was intended or would have been functionally appropriate.
Rigidity – Rigidity implies resistance to passive movements throughout the entire
range of movement and pressure.
Choreo athetosis – Choreo athetosis implies when the individual assumes
abnormal postures of the limbs, trunk, or head involving either slow, writhing
movements or rapid, dance like changes. All postures are assumed
involuntarily.
Ataxia – Ataxia implies when the child presents a poor balance with a wide-
based, unsteady gait and inaccuracy of reaching with swinging, and large
amplitude movements.
Intervention
The role of early intervention is important for the management of the child
with cerebral palsy. The earliest care can begin at the neonatal unit along
with the neurodevelopmental intervention. Neurodevelopmental intervention
would include:
 Facilitation of normal motoric patterns through staging appropriate motor
experiences,
 Facilitation of self smoothing and modulated tone changes by slow,
rhythmic handling,
 To develop normal oral feeding,
 Positioning for non-nutritive sucking, 91
Persons with Disabilities
 Oral-facial-tactile stimulation, and
 Promoting parent–child bonding.
Proper intervention would also involve appropriate and need based feeding
and positioning of the young child so as to avoid complications. The care
givers should be trained to use appropriate handling techniques of lifting,
carrying and providing sitting position for the child. Train the growing child to
communicate using all possible methods and modes to communicate and also
provide age based stimulation lest the child is under stimulated and mental
retardation sets in.
Parents must encourage the child to learn to be independent in taking care of
the daily needs of feeding, clothing, mobility, communication etc. An individual
with cerebral palsy requires intake of adequate nutrition, and stimulating
environment to be in a positive state of wellbeing.
Early physical therapy is one of the important aspects of early intervention. The
following modalities are used during physical therapy treatment of cerebral palsy:
 Giving warmth leads to muscle relaxation. This can be done by applying
warm soaks to spastic muscles before beginning the exercise regime.
 Cold applications can have the effect of reducing the muscle spindle
activity.
 The occurrence of deformity and activity of muscles can be reduced by
helping the child to do relaxed passive movements
 Exercises to stimulate opening of hand, developing hand grasp, and
pincer grasp can be done with the child.
19.4.4 Epilepsy
Epilepsy is a condition where there is uncontrolled episode of excessive electrical
activity in the brain leading to changes in behaviour, consciousness and movement.
Various types of epileptic seizures can be classified as follows:
 Partial seizures
These are rare and are present only in certain part of the body. They can
be simple or complex. There is no loss of consciousness in simple form of
epilepsy and the complex form is characterized by loss of consciousness
during the epileptic episode.
 Grand mal
During grand mal there is loss of consciousness, presence of convulsions,
and generalised and uncontrolled body movements. The individual usually
falls down during the episode and also may froth and urinate during the
seizure. The seizure lasts for about 2-3 minutes and the individual feels
exhausted after the episode and falls asleep after it is over. The individual
loses orientation and does not remember what happened during the episode.
 Petit mal
Petit mal type of seizure is characterized by loss of consciousness lasting
for about 3-15 seconds. During the seizure the person may stop all activity,
appear to be staring into space, seem like day dreaming, blinking eyes
92 rapidly. The individual may seem to lose muscular control.
 Psychomotor epilepsy Persons with Locomotor
Disability and Multiple
Psychomotor epilepsy lasts for usually 2-5 minutes and there are uncontrolled Disabilities
body movements, inappropriate actions as chewing, unaccountable violent
physical outbursts. It may also be accompanied with abdominal pains,
headaches and buzzing in the ears.
 Unclassified seizures
Causes
Epilepsy can be caused due to:
 Organic lesions as tumors in the brain
 Head injuries
 Fever
 Infections as meningitis
 Hereditary disorders as Batten’s disease
Steps to be taken during the episode of seizures
The following steps should be taken during the episode of epilepsy:
- The caregiver should remain calm.
- Ease the individual to the floor.
- Loosen clothing, keep airflow around the affected individual, prevent choking
on saliva or biting the tongue.
- Do not insert any object between the teeth and remove objects from the
vicinity to avoid accidents and injuries.
Remediation
The medical management of seizures includes drugs and surgery. Depending on
the type of the epileptic fit drugs can be prescribed by the trained doctors.
19.4.5 Cerebrovascular Accidents
Cerebrovascular accidents are also commonly known as stroke. It results due to
presence of blood clot in the brain thus inhibiting blood supply to the nerves,
thereby preventing the nerve from functioning in the normal fashion. If the treatment
does not begin within 24 hours of the stroke attack, the individual loses the ability
to talk, walk, use the upper limbs, control bowel activity or may also lose the
ability to recognise faces and situations, ability to hear and vision also. The risk
factors include high blood pressure, high blood cholesterol, diabetes, obesity,
smoking, and family history of stroke.
19.4.6 Arthritis
Arthritis refers to inflammation of the body joints due to auto immune causes,
infections, wear and tear, old age, etc.
Arthritis in adults is of different types such as osteoarthritis, rheumatoid arthritis,
septic arthritis and gouty arthritis.
Juvenile arthritis is a condition that can be identified by the presence of pain
and swelling in the joints of a child below 18 years of age and it mainly affects 93
Persons with Disabilities
children in the age range of 5 to 10 years. It results in pain, stiffness and swelling
in the joints.
Signs of the Disease
Persons affected by this condition suffer from the following:
 The joints are usually stiff in the morning and gradually loosen as the day
progresses. This condition is referred to as morning stiffness.
 There is presence of joint pain in the knees, ankles, wrists, neck, fingers,
toes, elbows and shoulders, hips and bones of the back.
 Development of contractures due to inadequate exercise and body positioning.
Types of Juvenile Arthritis
a. Systemic
Children with this condition show high “spiking” fever once or twice a day, visibly
enlarged lymph nodes, large spleens, rapidly changing flat pink rash and generalized
malaise and fatigue. Such attacks may last for months and appear and disappear
months or years later. Laboratory tests during the episode of illness may show the
child to be anaemic, having high WBC counts and sedimentation rates, non-
specific indications of severe inflammation.
b. Polyarticular
In addition to the rash, fever and anaemia the child also has severely involved
joints. Most frequently involved joints include knees, ankles, and wrists, neck,
elbow, fingers and shoulders. Later in the course, the hip joint also gets involved,
and also the jaw gets affected resulting in a receding chin due to interference in
the growth of the jaw bone. Such children are small for their age since the disease
interferes with the growth and sexual maturation of the individual. The joints also
lose their range of motion, then develop contractures and also subluxations.
c. Pauciarticular
This affects four or fewer joints. It mostly affects the knees, elbows, wrists and
ankles. Usually only one side of the body is affected.
Management
Management of arthritis includes drugs as analgesics, corticosteroids, anti rheumatic
drugs, biologic drugs, natural remedies and topical arthritis products and surgery
in extreme cases.

19.4.7 Muscular Dystrophy


Muscular Dystrophy is a condition where the body muscle fiber is replaced by
fat cells and the muscles gradually atrophy. Thus as the individual grows older the
muscles waste away and there is progressive loss of muscle power in the body.
It usually affects the male population and is also passed through the male progeny.
Early signs
The signs of this debilitating condition are:
 The well developed calf muscles of the young child feel rubbery as compared
94 to the calf muscles of the normal child. The child also walks on tiptoes.
 The child shows Gower’s sign — the child gets up by climbing on his own Persons with Locomotor
Disability and Multiple
body. Disabilities

 The child falls often when walking and cannot run.


 The feet of the child are affected initially, then the front of thighs, hips, belly,
shoulders, and elbow. Later in the course of the condition the face, hands,
and the neck muscles get affected.
 On reaching the teenage years, the children become wheel chair bound.
 The affected child develops lateral curvature of the spine due to weak muscles
of the back.
 The muscles of the heart and the respiratory system get affected in the
course of time.
 The affected individual suffers from pneumonia and heart failure as
complications.

19.4.8 Amputations
It is the loss or absence of whole or part of a limb. Amputations can be congenital,
due to accidents and also due to surgery to prevent spread of gangrene in the
body.

19.4.9 Club foot


It is a condition where the foot or both the feet are turned towards the inner side
i.e. towards the midline of the body.
Causes
This condition is caused due to congenital reasons, effect of drugs or due to
idiopathic reasons.
Types
It can be unilateral or bilateral. In case only one foot is affected the affected foot
is smaller and the calf muscles are also weak and thinner than the non-affected
leg.
Treatment
The corrective treatment includes the PONSETI method where the foot is
repeatedly stretched and plastered every week so that the tissues relax and the
foot is brought to the normal position slowly and with the course of time.

19.4.10 Leprosy
Leprosy or Hansen’s disease is caused by bacteria called mycobacterium lepre
that affects the mucous membrane, skin and the nerves of the peripheral nervous
system.
Signs
Early signs include light coloured patches that have lost sensation of pain. This can
be tested by scratching or pinching the affected area. Later lesions occur in that
area that are either macules (skin blemishes) or as plaques (scaly patches). Deformity
95
may also occur in the face and limb due to these lesions. In the hands the ulnar
Persons with Disabilities
nerve supplying the ring finger and the little finger is affected thus resulting in
clawing of these fingers. If all the nerves of the hand are affected it gives rise to
a total claw hand accompanied by wrist drop. If the nerves of the lower limb are
affected foot drop occurs and also dorsiflexion and planter flexion.
Causative factors
Bacterial infection can spread through nasal discharge from the infected person
and also the active leprosy patient is a potential source of infection for the
population in the vicinity. The bacteria thrive in hot humid climate and can also
spread through droplet infection from the sputum, skin lesions and mosquitos and
mites.
Management
Management of leprosy involves administration of drugs, treatment of deformities
with administration and use of splints, physical therapy and corrective surgery.

19.4.11 AIDS (Acquired Immuno Deficiency Syndrome)


The human immunodeficiency syndrome spreads through the means of human
blood, semen, saliva and vaginal secretions.
Symptoms
Signs of infection in women include repeated yeast infections (vaginal candidiasis),
pelvic inflammatory disease, growth and presence of precancerous cells in the
cervical tissue, genital ulcers, genital warts and severe mucosal herpes infections.
People may also develop flu like symptoms and at times they may also not show
any signs of infection. With years the signs may show as swollen lymph nodes in
the neck, underarm, groin area. There might be recurrent bout of fever including
“night sweats” and also rapid weight loss with no apparent reason. The person
might also feel tired constantly and white spots or unusual blemishes may appear
in the mouth.
Complications in AIDS
The AIDS Virus does not directly attack the nervous system but the reduced
vitality of the immune system leads to inflammation and damage to the brain and
spinal cord. Neurological complications associated with AIDS include Vacuolar
Myelopathy where symptoms include weak and stiff legs, unsteady walking and
in the last stages the patient requires a wheel chair. Stroke and progressive
multifocal leucoencephalopathy are other conditions that can be associated with
AIDS. Both conditions are characterized by paralysis of the limbs.
Prevention
It includes practising safe sexual behaviour with preferably one partner, and use
of contraceptives. Also avoid use of intravenous needles and take care of the
genuineness of the blood units taken during medical emergencies.

19.4.12 Diabetic Neuropathy


This condition arises due to long term state of diabetes where one of the symptoms
includes wasting of the muscles of the hands and feet. Peripheral neuropathy leads
to muscle weakness and loss of reflexes, especially at the ankle leading to
96 changes in the way a person walks. Deformities as hammertoes, and the collapse
of the midfoot may occur. Due to numbness in the regions, sores and blisters may Persons with Locomotor
Disability and Multiple
occur that go unnoticed and through which infection sets in the skin and the bones Disabilities
leading to amputations in the future if not treated promptly.

19.4.13 Gout
The arthritis caused by gout results when deposits of uric acid crystals in the joint
fluid and joint lining occur. Inflammation results causing pain and redness in the
joint tissues.
Gouty arthritis is typically an extremely painful attack with a rapid onset of joint
inflammation. The joint inflammation is precipitated by deposits of uric acid crystals
in the joint fluid (synovial fluid) and joint lining (synovial lining). Intense joint
inflammation occurs as white blood cells engulf the uric acid crystals and chemical
messengers of inflammation are released, causing pain, heat, and redness of the
joint tissues.
Check Your Progress Exercise 3
Note: a) Read the following questions carefully and answer in the space
provided below.
b) Check your answers with those provided at the end of this Unit.
1. Define the terms grand mal, hemiplegia and muscular dystrophy.
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2. Discuss how AIDS can be a source of locomotor disability.
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19.5 PREVENTION OF LOCOMOTOR


DISABILITY
The prevention of locomotor disability can be taken care of at three levels:
primary, secondary and tertiary.

Primary level of prevention: This approach stresses on the prevention of


occurrence of the disease or condition. It includes taking steps to ensure that the
disability condition does not occur. This can be done by propagating the message
of attaining and maintaining general health conditions by giving information about
adequate nutrition, taking safety measures to prevent accidents at home, at
workplace etc. It also includes propagating the positive effects of following a 97
Persons with Disabilities
healthy lifestyle, making certain behavioural changes, maintaining proper hygiene
and sanitation. It also includes making people aware and appreciating the need
for proper immunization and also following rules and regulations when working in
hazardous environments.

Secondary level of prevention: This refers to the early steps taken to control
the disease and the disability when it has occurred. It aims at halting or slowing
down the progress of the debilitating condition and also preventing the complications
bound to arise if the condition is allowed to progress. For example deformities
due to paraplegia can be prevented by taking care of positioning the affected
individual in the bed and when doing different activities. Also occurrence of
pressure sores can be prevented if care is taken in case of traumatic paraplegia.

Tertiary level of prevention: This involves proper rehabilitation of the affected


individual when the disability has occurred.

Check Your Progress Exercise 4


Note: a) Read the following question carefully and answer in the space
provided below.
b) Check your answer with that provided at the end of this Unit.
1. People working in factories at times do not follow rules. Comment.
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19.6 PROBLEMS FACED BY THE


LOCOMOTOR DISABLED PERSON
The locomotor disabled persons suffer from the following conditions:
Motor weakness: The body is weak and there is less strength in the muscles of
the limbs and the joints leading to motor weakness.
Motor weakness refers to either complete or partial weakness. Complete weakness
results in paralysis and partial weakness leads to severe pains etc. Both of these
kinds of weakness result in deficiencies in areas of daily living. It requires
rehabilitation intervention in maintaining the range of movement of joints of the
affected limb, to regain or improve the muscle power in the weak muscles.
Paralysis: Paralysis is a loss of sensation in the affected limb so that the limb
does not experience any sensation and also cannot make both voluntary and
involuntary movements.
Spasticity: Spasticity is defined as a state of increased muscle tone proportional
to the velocity of stretch applied. Spastic muscles have varying degree of weakness
and incoordination. Thus repetitive activities requiring rhythmic contraction and
relaxation are impaired. Long term spasticity leads to contracture and deformities.
98
It is important to control spasticity so as to improve muscle coordination, balance, Persons with Locomotor
Disability and Multiple
strength, range of motion of joints for appropriate training for activities of daily Disabilities
living, walking and vocational rehabilitation. It can be controlled with the help of
range of motion exercises, hydrotherapy, maintenance of appropriate posture and
removal of any irritating focus below the level of lesion.
Sensory loss: Due to injury to the spinal cord, the nerves that are responsible for
bringing about transmission of sensory information get damaged and thus the
individual loses the ability to feel pain or discomfort.
Pressure ulcers: Due to long contact of the skin with the surface of bed where
the immobile person lies, he or she may develop pressure sores at the area of
contact that might begin to bleed and also get infected. They are areas of necrosis
resulting due to prolonged excessive pressure on the soft tissues. They occur due
to immobility, motor weakness, loss of sensation, excessive perspiration, urinary
and faecal soiling, rough and crinkly bed sheet and lack of care. The common
sites where bed sores occur are the sarum, back of the heels, and the trocanter.
Deformities and contractures: Due to weak muscle control and inappropriate
posture the individual’s body takes up a postural position that is non painful
and in the process leads to permanent deformity and contractures. Deformity
is defined as an abnormal position, which is not passively corrected, and is
assumed by the part of the body due to some disease or injury. Factors that
lead to deformity include habitual faulty posture, muscle weakness, muscle
imbalance, gravity, faulty walking pattern, limb length discrepancy etc.
Contracture refers to a permanent shortening of the muscle that causes
deformity with or without pain. It can be avoided with frequent changes in
position and range of motion exercises.
Loss of limbs or other body parts: This can result due to accidents, skin lesions
and infections, accidents, warfare, affect of drugs during prenatal period, etc.
Urinary and faecal incontinence: This can occur due to loss of sensation to the
brain about the need to urinate and also can be due to loss of muscular control
in the affected organs. Bladder and bowel dysfunction due to impaired neural
control is commonly called “neurogenic” bladder and bowel. Long term
complications of these include chronic prostates, stricture urethra, hydronephrosis
and chronic renal failure.
Check Your Progress Exercise 5
Note: a) Read the following question carefully and answer in the space
provided below.
b) Check your answer with that provided at the end of this Unit.
1. Name three problems that may be faced by persons with locomotor disability.
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99
Persons with Disabilities
19.7 MULTIPLE DISABILITIES
Multiple disabilities have been defined as the combination of more than one
disability in a person. It includes children who have two or more of the following
conditions:
 Varying degrees of mental retardation
 Cerebral palsy
 Autism
 Blindness or low vision
 Deafness or hearing loss
 Physical disability as polio, paralysis, delayed motor development
 Neurological impairment
 Communication disorders
The combination of disabilities may vary from child to child and the degree of
severity may also vary.
The age of onset of the condition can be since birth till teen years. Children may
be born with one disabling condition but may also acquire the second or the third
disabling condition in the following years.
Also a combination of disabilities may interact over time and in turn lead to
developmental arrest and secondary complications which in turn may lead to
physical or mental disorders such as deformities or contractures and psychiatric
disorders.

19.7.1 Causes of Multiple Disabilities


Causes of multiple disabilities can be grouped under headings of pre-, peri- and
postnatal as in case of single disabling conditions but with the result of interaction
of the condition and the environmental factors may lead to a multiple disabling
conditions. For example, the condition of Hydrocephaly can occur alone but it
may be complicated by the effects of prematurity or birth asphyxia and have a
precursor condition of spina bifida.
Examples of Multiple Disabilities
Conditions such as congenital Rubella, other infections due to viral teratogens,
progressive neurological disorders such as mucopolysaccaridoses, rare metabolic
disorders as Hurler syndrome, Duchenne and other muscular dystrophies, primary
orthopedic problems such as arthrygryphosis multiplex congenital, primary muscle
aplasia, lower motor neuron diseases and motor neuropathy, congenital
amputations, defective limb bud rotation syndrome are examples of cases leading
to multiple disabilities.
The categories of individuals with multiple disabilities can vary as deaf-blind,
blind-mentally retarded, blind-cerebral palsy etc.
Each group varies with the needs, limitations and capabilities and also individuals
belonging to one category can also differ in their individual needs. The deficits can
100 be seen in the following areas:
 Self help skills: Such as dressing, feeding, bowel movements, and bladder Persons with Locomotor
Disability and Multiple
control. Disabilities

 Communication behaviour: These include speech difficulties, understanding


and expression of language.
 Physical and motor behaviour: Such as maintaining posture, balance, mastery
of gross and fine motor skills, mobility etc.
 Social skills: Such as participating in group activities requiring interpersonal
interaction, exhibiting appropriate social and emotional behaviour.
 Presence of inappropriate behaviours and emotional disturbances: These
may include aggression, withdrawal, shyness, suicidal tendencies, ritualistic
behaviour, self injurious behaviour etc.

19.7.2 Prevention
The causes of multiple disabilities are numerous and are a result of interaction of
causal factors in varying degrees and intensities. Thus prevention is important
though not controllable. However prevention would include taking steps towards
preventing the occurrence of disability at the critical stages when it is most likely
to manifest during the development of the individual in the mother’s womb.
At the prenatal stage the following precautions should be taken by the
pregnant mother:
i. She should abstain from alcohol intake and exposure to smoking both active
and passive.
ii. She should avoid situations that might lead to accidents and injuries to the
unborn child.
iii. Regular checkup at the maternity clinic and undertaking various screening
procedures on the medical advice should be taken care of.
iv. The expectant mother should be vaccinated for infections such as rubella,
chicken pox etc.
v. Vitamin supplementations of Folic acid, iodine, Vit K and iron should be
given to the expectant mother.
vi. Conditions as blood pressure, diabetes, thyroid problems should be kept
under check for the pregnant mother.
Steps to be taken at the time of delivery:
i. Steps should be taken to ensure that delivery occurs in a clean and hygienic
environment under specialized supervision.
ii. Complications during delivery such as breech and assisted delivery should be
handled with utmost care and expertise.
For the neonate the following points should be kept in mind:
i. The newborn should be fed and kept warm immediately after birth.

ii. Cases of neonatal jaundice should be immediately taken under medical


supervision. 101
Persons with Disabilities
iii. Check newborn for early signs of epileptic fits and intervention should start
at the earliest.
iv. Conditions of neural defects, macrocephaly, microcephaly should be identified
and prognostic steps should be taken immediately.
v. The Apgar score of the neonate should be considered and steps should be
taken to control deficient condition.
During the post natal stage the growing child should be provided with adequate
nutrition, given timely vaccine to avoid nutritional deficiencies and infections. Also
avoid over exposure to pollutants and irradiation. Accidents and injuries to the
head of the children should be avoided and in case of occurrence immediate
medical intervention should be provided.
19.7.3 Intervention
Steps to be taken to minimize the effects of the disabling condition include the
f\ollowing:
 Providing adequate nutrition to the growing child so that the immune system
works to its full potential to fight secondary illness and infections and maintain
growth and strength of the body and the brain.
 Provide for occupational and physiotherapy if the need arises
 Teaching of appropriate body movements of the body to avoid deformities
and contractures
 Teaching adaptive behaviour to blind and deaf children to be more in control
of their environment
 Provision of need based medication and early intervention and also giving
importance to the need for stimulation of the mind and the body from early
age.
 Provision for surgery if the case needs as in case of hydrocephaly.
Check Your Progress Exercise 6
Note: a) Read the following question carefully and answer in the space
provided below.
b) Check your answer with that provided at the end of this Unit.
1. What are the precautions a pregnant woman can take to avoid disability
in her child?
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19.8 REHABILITATION
Rehabilitation refers to the restoration of the physically disabled persons to their
102 maximum possible physical, educational, economic independence and social
integration. The process of rehabilitation takes into account the level of recovery Persons with Locomotor
Disability and Multiple
possible with each case of disability. Thus there are patients who can fully recovery Disabilities
as in cases of neuropraxis, surgically repaired nerve injuries, Guillain Barre syndrome
etc. In certain cases the patient exhibits permanent but stable disability as in
amputations, post polio residual paralysis, nonprogressive paraplegia, hemiplegia
etc. There are also patients with unstable disabilities such as rheumatoid arthritis,
osteoarthritis etc.
The process of rehabilitation should include the following:
 Prevention of disability,
 To reduce or eliminate the disability to the maximum, and
 To train the affected individual to achieve independent living with whatever
residual abilities one has.
Assistive Devices
Assistive devices are any devices that can help persons with disabilities in doing
activities of daily living; they are items that can directly enable people with disabilities
to participate in the activities of daily life. People may take help of assistive
devices on their own or with help of other people.
Orthotics
This includes the provision of splints and appliances that improve the function and
appearance of a disabled person. An orthosis can be said to be an appliance that
is added to the patient, to enable better use of the body part to which it is fitted.
Functions of orthetics
The main function and aim for which orthoses are prescribed are to prevent and
correct any deformity arising out of the disability. It also provides relief from pain
as it limits motion and weight bearing. It also leads to immobilization and protection
of weak, painful or healing musculo-skeletal segments. It also leads to improvement
in the function of the specific limb.
Prosthetics
Prosthetics refer to any artificial substitute for lost part of the body. They can be
external or internal. External prosthesis is used for upper and lower limbs and can
also be further classified into endoskeletal limbs or conventional limbs or temporary
pylon prosthesis.
Functions of prosthetics
Rehabilitation by the use of prosthetics aims at achieving maximum function out
of the remaining stump of the lost or missing limb.
The points to keep in mind when choosing the appropriate prosthetic is to take
care of the following:
 The level of amputation
 Type of socket
 Material of socket
 Type of joint to be used i.e., hip, knee, or elbow mechanism, ankle/foot or
hand/terminal appliance 103
Persons with Disabilities
Cosmetics
It is the preservation, restoring or bestowing of bodily beauty. In terms of prosthetics
it implies creation of life like limbs mimicking the real limb.
Walking Aids
Walking aids are used to increase the mobility of a patient. This is done when
some of the weight of the body can be supported by the upper limbs. Examples
of walking aids include parallel bars, walking frames, crutches and sticks etc.
Selection of the walking aid depends upon the stability of the patient, the strength
of the upper and the lower limbs, presence of degree of coordination of movement
of the upper and lower limbs and the degree of relief from weight bearing equipment
that is required.
Types of walking aids include crutches, frames, sticks and parallel bars.
Rehabilitation using walking aids requires time. The patient needs to regain strength
after a prolonged illness. This can be gained by taking adequate diet and well
planned progressive course of exercise. The patient also needs to become free
of the fear of falling.
Architectural barriers
Patients with locomotor impairments are not in a position to walk through narrow
entrances, lanes on elevated platforms, etc. So it is necessary to provide special
ramps, remodeling of entrances, widening of doors, construction of slopes instead
of stairs, and creation of plain, flat floors without raised obstacles in the house and
public places also.
Psycho-social rehabilitation
Illness and injury lead to anxiety and frustration. Care should be taken to boost
the morale of the disabled person and feeling of empowerment should be inculcated.
The people surrounding them should be supportive, helpful and not indulging in
pity for the disabled. The response to the incapacity depends upon the patient’s
personality, education, social and economic situation. Care should be taken to
include these factors when planning for the individual’s s rehabilitation goals.
Specific psychological problems of persons with disabilities include depression,
anxiety, feeling of insecurity, and inability, loneliness, behavioural disorders, affective
disorders, personality disorders, suicidal tendencies, dependence, low self esteem,
irritability, impaired psychomotor coordination and hysteria.
Check Your Progress Exercise 7
Note: a) Read the following questions carefully and answer in the space
provided below.
b) Check your answers with those provided at the end of this Unit.
1. Enumerate the types of walking aids.
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104 ------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------ Persons with Locomotor
2. Name some of the psychological problems of persons with multiple Disability and Multiple
disabilities. Disabilities

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19.9 LET US SUM UP


Locomotor disability is a condition that affects the mobility and body movements
of the affected individual. It can be acquired at birth, be present congenitally, or
occur due to accidents and traumas during the course of the life span. Its early
diagnosis is thus necessary and important to check its further progress. It requires
a team of different professionals to work towards intervention and rehabilitation
of the affected person.
The case becomes more complicated when the condition of multiple disabilities
occurs that leads to complex issues in prevention, complications, intervention and
rehabilitation. A single disabling condition is much easier to check and control than
a case of multiple disabilities as each limiting condition plays a role in compounding
the disability in itself and also limits the development and use of other faculties for
the growth and development of the affected individual.

19.10 GLOSSARY
AIDS : Acquired Immuno Deficiency Syndrome
Hemiplegia : Paralysis of half of the body.
Locomotor disability : An individual’s inability to execute distinctive
activities associated with moving both oneself
and objects from one place to another.
Musculoskeletal impairment : A result of the involvement of the muscles and
bones of the body.
Multiple Disabilities : Combination of more than one disablity in a
person.
Neuromuscular impairment : A result of the involvement of the muscles and
nerves in the body.
Paraplegia : Paralysis of two lower limbs.
Quadriplegia : Paralysis of all the four limbs.

19.11 ANSWERS TO CHECK YOUR PROGRESS


EXERCISES
Answer to Check Your Progress Exercise 1
1. Locomotor disability can be defined as an individual’s inability to execute
distinctive activities associated with moving both oneself and/or objects from
one place to another because of any musculoskeletal and/or nervious system 105
malfunction.
Persons with Disabilities
Check Your Progress Exercise 2

1. Neuromuscular condition that leads to locomotor disability is an impairment as


a result of the involvement of the muscles and the nerves in the body.

Check Your Progress Exercise 3

1. Grand mal is a type of epileptic seizure wherein there is loss of conciousness


and pesence of convulsion and generalised and uncontrolled body movements.
The individual usually falls down during the episode and may also froth and
urinate during the seizure. The seizure lasts for about 2 to 3 minutes and the
individual feels exhausted after the episode and falls asleep after it is over. The
individual losses orientation and does not remember what happened during the
episode.

Hemiplegia is a type of spinal cord injury in which paralysis of half of the body
takes place.

Muscular dystropy is a condition where the body muscle fiber is replaced by fat
cells and the muscles gradually atrophy.As the person grows older fat cells and
the muslces waste away and there is progressive loss of muscle power in the
body.

2. Neurological complications which are associated withAIDS lead to weak and


stiff legs, unsteady walking and in the last stages the patient requires a wheel
chair. This condition classfiesAIDS as a source of locomotor disability.

Check Your Progress Exercise 4

1. It is true that at times people working in a factory do not follow rules and
regulations. This makes them prone to hazardous conditions and accidents which
maylead them to live a disabled life in future especiallylike locomotor disability.

Check Your Progress Exercise 5

1. Pressure ulcers, deformities and contractures, and loss of limbs or other body
parts.

Check Your Progress Exercise 6

1. The pregnant women should take utmost care of herself to look after her child.
She should avoid alcohol, smoking both active and passive, radiations, drugs
and medicines without a prescription from the doctor. She should go for regular
health check-ups at materinityclinics and strictlyfollow the advice of the doctor.
She should take vaccination for rubella, chicken pox, etc. She should take
vitamin K, iodine, iron, etc. Conditions like diabetes, thyroid, blood pressure,
etc. should be kept under control.

Check Your Progress Exercise 7

1. Types of walking aids are crutches, frames, sticks and parallel bars.

2. Someof thecommon psychological problems of persons with multipledisabilities


are depression, anxiety, feeling of insecurity, inability, loneliness, behavioural
and emotional disorders.

106
Persons with Locomotor
19.12 UNIT END QUESTIONS Disability and Multiple
Disabilities
1. Discuss the complications faced by the locomotor disabled persons if proper
care is not taken.
2. What is the role of assistive devices in the rehabilitation of the locomotor
disabled?
3. Elaborate why is psycho-social rehabilitation of the locomotor disabled
important?
4. How do deformities and contractures occur in a cerebral palsied child?
5. Discuss the role of a multidisciplinary team in the care of a person with
disabilities.

19.12 FURTHER READINGS AND REFERENCES


Black. E.E, Nagel. D.A (1975); PhysicallyHandicapped Children-A medical
Atlas for Teachers. Rune & Stratton Inc.
Beyond Tokenism-A guide for teachers on how to implement inclusive
education in the regular class. National Trust Publication.
Cerebral palsy, National trust Publication
Caregivers Manual, National Trust Publication
Fox, A. M. An Introduction to neuro developmental disorders of children.
The National Trust Publication.
Gordon, N. & Mc Kinley. I. (1987). Neurologically Handicapped Children:
Treatment and Management (Ed), Blackwell Scientific Publication.
Jha, A. (1999) Curriculum Guidelines for Students with Multiple Disabilities:
Physical and Neurological (Ed). Calcutta: Indian Institute of Cerebral Palsy.
Manual for training of PHC Medical Officers (2001). New Delhi: Rehabilitation
Council of India.
Nair, M.K.C. & Pejavar, R. K. (2000). Child development and beyond ability
matters. Retrieved from www://ie/orthotics_&_paediatrics.html#ctev.
Training in The Community for People With Disabilities, 1989 WHO.
Werner, D. (1994) Disabled Village Children; Voluntary Health Association of
India.
www. Medicinenet.com retrieved on 16-06-2009
www. Diabetes.niddk.nih.gov/dm/pubs/neuropathies
www.avert.org/symptoms.htm retrieved on 10-06-2009

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