PPT ON MENTALLY CHALLENGED CHILDREN OR MENTAL RETARDATION IN CHILDREN

BY
M. Sandeep kumar
MSC NURSING 2ND YEAR
SVIMS, TIRUPATI.
MENTALLY CHALLENGED
Thursday, January
28, 2016
1

INTRODUCTION……
 Challenged condition makes the normal function of
individual very difficult and leads to dependency. These
conditions are increasing day by day due to changing
lifestyle and complicated environment.
 Challenged children is one who deviated from normal
health status either physically, mentally or socially and
requires special care, treatment and education.
Thursday, January 28, 2016
M. Sandeep kumar
2

CONCEPT OF CHALLENGED…….
 According to WHO the sequence of events leading to
disability and handicapped OR challenged conditions
are as follows.
M. Sandeep kumar
INJURY OR DISEASE IMPAIRMENT DISABILITY
CHALLENGED OR HANDICAPPED

IMPAIRMENT….?
 It is defines as any loss or abnormality of psychological,
physiological or anatomical structure or function, e.g.
Loss of vision, loss of hearing, etc. Primary impairment
may leads to secondary impairment e.g. Defective
hearing results in learning difficulties and poor school
performance.
 Impairment leads to disability.
M. Sandeep kumar
4

DISABILITY….?
 It develops as the consequence of impairment. E.g. Loss
of limbs results in inability to walk. Disability is the
inability to carry out certain activities which are
considered as normal for the age and sex.
M. Sandeep kumar
5

HANDICAPED OR CHALLENGED..?
Handicap is defined as a disadvantage for a given
individual resulting from an impairment or a disability,
that limits and prevents the fulfillment of a role which is
normal for that individual, depending, on age, sex, social
and cultural factors. primary handicap may lead to
secondary handicap condition e.g. Blindness leads to
economical handicapped situation.
M. Sandeep kumar
6

Classification…..
M. Sandeep kumar
7

1. Physically challenged
 physically challenged children can be grouped
according to affected part of the body. These include
orthopedically handicapped, sensory handicapped,
neurologically handicapped and handicapped due to
systemic diseases.
M. Sandeep kumar
8

2. Mentally challenged
 Mentally challenged is now used for the condition
mental retardation. At least 2 - 3 percent of Indian
population are mentally handicapped in any one form.
Cognitive impairment is also used as synonym for
mentally challenged or mental retardation.
M. Sandeep kumar
9

3. Socially challenged
 Socially challenged children are having disturbed
opportunities for healthy personality development due
to social factors leading to non- achievement of full
potentialities. Social disturbances are found in the
form of broken family, parental inadequacy, loss of
parents, poverty, lack of educational opportunities,
environmental deprivation and emotional
disturbances as lack of tender loving care.
M. Sandeep kumar
10

Mentally challenged…,
 Intellectual disability (ID), also called intellectual development disorder
(IDD) and formerly known as mental retardation (MR). Mental retardation
(MR) is a developmental disability that first appears in children under the
age of 18. It is characterized as a level of intellectual functioning (as
measured by standard intelligence tests ) that is well below average and
results in significant limitations in the person's daily living skills (adaptive
functioning).
 The term MR as offensive and the term intellectual disability or
intellectually challenged is now preferred by most advocates in most
english speaking countries.
M. Sandeep kumar

Definition:-
 Mental retardation refers to significantly sub average general
intellectual functioning (BELOW 70) resulting in or associated
with concurrent impairments in adaptive behavior and
manifested during the developmental period.
- American association on mental deficiency,1983.
M. Sandeep kumar
12

KEY WORDS………….
 Significant sub average is defined as an intelligence quotient (IQ)
of 70 or below on standardized measures of intelligence.
 Adaptive behavior is defined as the degrees with which the
individual meets the standards of personal independence and
social responsibility expected of his age and cultural group. The
expectations of adaptive behavior vary with the chronological age.
M. Sandeep kumar
13

Adaptive
skill
areas.?
M. Sandeep kumar
14

The deficient in adaptive behavior
1. During infancy and childhood
 Sensory and motor skill development
 Communication skill (including speech and language)
 Self-help skills.
 Socialization.
2. During childhood and adolescent
 Application of basic academic skill to daily life activities.
 Application of appropriate reasoning and judgment in the mastery of the
environment.
 Social skill.
3. During late adolescent
 Vocational and social responsibilities and performance.
 Note:- developmental period is defined as the period of time between conception
and the 18th birth day.
M. Sandeep kumar
15

Epidemiology…….?
 3 % of the world population is estimated to be mentally retarded.
 In India 5 out of 1000 children are mentally retarded (Indian express 13th march 2001). More
than 20 million children are suffering with mental retardation.
 Mental retardation is more common in boys than girls.
 Mortality is high in severe or profound mental retardation due to associated physical
condition.
 Common in the age group of 2 -3 years. Peak in 10–12 years of age.
M. Sandeep kumar
16

Etiology
Genetic factors
1. Chromosomal abnormalities:-
 Down’s syndrome
 Fragile X syndrome
 Trisomy X syndrome
 Turner’s syndrome
M. Sandeep kumar

Down syndrome.
 About one-half of all cases of mental retardation are caused by
known biological abnormalities like Down syndrome.
 The cause of Down syndrome is the presence of an extra
chromosome.
 In general, children and adults with Down syndrome function within
the moderate to severe range of mental retardation. M. Sandeep kumar

Fragile-X syndrome
 Fragile-X syndrome, is the most common known genetic cause of
mental retardation.
 Fragile-X syndrome is indicated by a weakening or break on one arm
of the X sex chromosomes, and it is transmitted genetically.
 Not all children with the fragile-X abnormality have mental retardation.
 As in fragile-X syndrome, abnormalities of the sex chromosomes are
particularly notable.
M. Sandeep kumar
19

Etiology
2. Metabolic disorders:-
Phenylketonuria
Wilsons syndrome
Galactosemia
M. Sandeep kumar

Phenylketonuria…..
 PKU is caused by abnormally high levels of the amino acid phenylalanine,
usually due to the absence of or an extreme deficiency in phenylalanine
hydroxylase, an enzyme that metabolizes phenylalanine.
 Children with PKU have normal intelligence at birth.
 However, as they eat foods containing phenylalanine, the amino acid builds
up in their system.
 This phenylketonuria produces brain damage that eventually results in mental
retardation.
 Retardation typically progresses to the severe to profound range.M. Sandeep kumar

Etiology
3. Cranial malformation
Hydrocephaly
Microcephaly
4. Gross diseases of brain
Tuberous sclerosis
Neurofibromatosis
Epilepsy
M. Sandeep kumar
22
Etiology

Etiology
Prenatal factors:-
Infections:- [ STORCH ]
 Rubella
 Cytomegalovirus
 Syphilis
 Toxoplasmosis
 Herpes simplex.
Endocrine disorders:-
 Hypothyroidism
 Hypo parathyroidism
 Diabetes mellitus
M. Sandeep kumar

INFECTIONS….
 Rubella (German measles) is a viral infection that may produce few
symptoms in the mother but can cause severe mental retardation and even
death in the developing fetus.
 The human immunodeficiency virus (HIV) can be transmitted from an
infected mother to a developing fetus.
 The effects on the child are profound, including mental retardation, visual
and language impairments, and eventual death.
M. Sandeep kumar

INFECTIONS….
 Syphilis is a bacterial disease that is transmitted through sexual
contact. syphilis produces a number of physical and sensory
handicaps in the fetus, including mental retardation.
 Another sexually transmitted disease, genital herpes, can be
transmitted to the infant during birth and result in mental retardation.
 Two infectious diseases that occur after birth, encephalitis and
meningitis, can cause mental retardation.
M. Sandeep kumar

Etiology
M. Sandeep kumar
26
Physical damage and disorders:-
 Injury
 Hypoxia
 Radiation
 Hypertension
 Anemia
 Emphysema
Intoxication:-
 Lead
 Certain drugs
 Substance abuse

Etiology
Placental dysfunction:-
Toxemia of pregnancy
Placenta previa
Cord prolapse
Nutritional growth retardation
M. Sandeep kumar
27

Etiology
Perinatal factors:-
Birth asphyxia
Prolonged and difficult birth
Prematurity (due to complications)
Kernicterus
Instrumental delivery (resulting in head injury,
intraventricular hemorrhage)
M. Sandeep kumar

Etiology
Postnatal factors:-
Infections:- Encephalitis,
Measles,
Meningitis,
Septicemia.
Accidents.
Lead poisoning
M. Sandeep kumar
29

Etiology
Pregnancy and birth complications
 One major complication is Rh incompatibility.
 Another pregnancy and birth complication that can cause
intellectual deficits is premature birth.
 particularly anoxia, or oxygen deprivation; severe
malnutrition; and the seizure disorder epilepsy. M. Sandeep kumar

Etiology
Environmental and social-cultural factors:-
 Cultural deprivation
 Low socio-economic status
 Inadequate caretakers
 Child abuse
M. Sandeep kumar
31

PREDISPOSING FACTORS
 Low socioeconomic strata or poverty.
 Low birth weight of children.
 Advanced maternal age.
 Consanguinity.
 Extreme malnutrition.
 Lack of stimulating environment Poor sensory experience.
 Poor sensory experience
M. Sandeep kumar
32

PREDISPOSING FACTORS
 Defective low standard education due to defective scholastic
environment.
 Psychological disadvantage. E.g. poor health practices, poor
housing, disuse of language, etc.
 Parental deprivation
 Prolonged isolation of care takers during developmental period.
 Sensory deprivation and social deprivation.
M. Sandeep kumar
33

Classification…….;
 Intelligent quotient is the ratio between mental age (MA) and
chronological age (CA). while chronological age is
determined from the date of birth , mental age is determined
by intelligence test.
M. Sandeep kumar
34

TYPES OF MENTAL RETARDATION
Type IQ range in mental retardation
1. Mild (Educable) 50 - 70
2. Moderate (Trainable) 35 - 50
3. Severe (Dependent retarded) 20 - 35
4. Profound (Life support) < 20
M. Sandeep kumar
35

Mild retardation (Educable) (IQ 50-70):-
 85-95% of total mental retardation cases belong to mild mental retardation.
 Environmental influences, psycho social deprivation, restrictive child rearing practices,
malnutrition, low-socio-economic class are the causes for mild mental retardation.
 They have deficient in intellectual skills, studies up to 6-8th standard, problem in reading and
writing, difficult in academic school work, normative living skills, walking, talking, toilet
training, language abilities, and development of domestic skill, behavior, social and emotional
adjustment like a normal person.
 Can fully adjust educable, finds difficulty in complex ideas, drawing generalization, can learn
motor skills better than verbal skill and writing, emotionally they are stable, overactive, temper
tantrum is common, can understand simple terms, they can be trained in special school.
 In adult life most of them lead independent life in normal surroundings.
M. Sandeep kumar
36

Moderate retardation (Trainable) (IQ 35-50)
 10% of mental retardation cases belong to moderate mental retardation.
 Children can be trainable, aimed at self-help skills, they can speak and
support themselves, able to perform semi-skilled or unskilled work under
supervision can learn few basic skills.
 Communication skills develop much slowly, limited progress in
scholastic work, studies up to 2nd grade, unaware of needs, have less
neuro pathological complications, partially depends on others for their
care.
M. Sandeep kumar
37

Severe retardation (Dependent) (IQ 20-35)
 7% of total mental retardation cases, belong to severe MR.
 Slow motor development in preschool years, trainable for normal living
activities, allow them to do daily living activities under supervision,
contributes partially to self-maintenance, some children may learn social
behavior , able to communicate in simple way , engaged in limited
activities, delayed speech and communication skills.
M. Sandeep kumar
38

Profound retardation (Life support) (IQ < 20)
 1-2% of mental retardation cases are profound type.
 considerable organic pathology, nervous system is noticed,
associated conditions are; blindness, deafness, seizures are
common, delayed milestones, motor impairment, totally
dependent, cannot do anything on their own.
 Death may occur due to variety of problems or complications.
M. Sandeep kumar
39

Mental Retardation
Symptoms of Mental Retardation..
However, all definitions generally agree on the three major
criteria for mental retardation:
1) significant limitations in intellectual functioning,
2) significant limitations in adaptive functioning, and
3) onset before age 18 years.
M. Sandeep kumar

SIGNS AND SYMPTOMS
 Failure to achieve developmental milestones.
 Deficiencies in cognitive functioning such as inability to
follow commands or directions.
 Reduced ability to learn or to meet academic demands.
 Expressive or receptive language problems.
 Psychomotor skill deficits.
M. Sandeep kumar

SIGNS AND SYMPTOMS
 Difficulty performing self-care activities.
 Neurologic impairment
 Medical problems such as seizures
 Low self-esteem, depression and labile moods
 Irritability when frustrated or upset
 Acting-out behavior
 Lack of curiosity
M. Sandeep kumar
42

Diagnosing MR……./
 The diagnosis of mental retardation is usually made after a
period of suspicion by professionals or family members that the
child’s developmental progress is delayed.
 In some cases it is conformed at birth because of recognition of
district syndrome.
 Routine developmental screening can assist in early
identification.
M. Sandeep kumar
43

Diagnosing MR…….//
 Multidisciplinary evaluation should be individually tailored to the
child. A team of professionals like pediatric neurologist,
developmental pediatrician, psychologist, social scientist, speech
therapist, physical therapist, special educator, social worker and
nurse will evaluate the child.
 Complete history is collected from family members and care
takers.
M. Sandeep kumar
44

Diagnosing MR…….///
 Mental history
 Physical examination to exclude physical illness.
 Neurological assessment
 Assessment of mile stones like intellectual levels, cognitive ability,
language pattern and communication skills, hearing, conative
behavior.
M. Sandeep kumar
45

Diagnosing MR…….////
Investigations,,,,,,
 Urine and blood examination for metabolic disorders.
 Hormonal studies- T3, T4, TSH when cretinism is suspected.
 Culture for cytogenic and biochemical studies.
 EEG to exclude seizures.
 MRI, CT scan to study the structural abnormality of brain for example
tuberous sclerosis.
M. Sandeep kumar
46

Diagnosing MR……./////
Investigations,,,,,,
 Antibodies for diagnosing infections, LFT in Wilson’s disease.
 Sensory test – assessment for vision, hearing.
 Amniocentesis for pregnant mothers to detect chromosomal
abnormalities, chorionic villi sampling, chromosomal analysis.
 Education evaluation- reading, writing, regularity in schooling, living
learning skills, daily living skills, social abilities.
M. Sandeep kumar
47

Diagnosing MR…….//////
 Psychological investigation includes Stanford Binet intelligence
tests (mental abilities) 2 years and more. Wechler’s intelligence
scale for children WISC (above 6 years)
 Through the psychological testing the mental age of the child
estimated. The intelligence quotient is then determined using
the formula.
M. Sandeep kumar
48

Early behavioral signs suggestive of
MR
1) Dysmorphic features (e.g. down syndrome, fragile X
syndrome).
2) Irritability or unresponsiveness to contact.
3) Abnormal eye contact during feeding.
4) Gross motor delay.
5) Decreased alertness to voice or movement.
6) Language difficulties or delay
7) Feeding difficulties.
M. Sandeep kumar
49

Treatment modalities for MR……
 Behavior management.
 Environmental supervision.
 Monitoring the child’s developmental needs and problems.
 Programs that maximize speech, language, cognitive,
psychomotor, social, self-care, and occupational skills.
 Ongoing evaluation for overlapping psychiatric disorders, such
as depression, bipolar disorder, and ADHD.
M. Sandeep kumar
50

Treatment modalities for MR
 Family therapy to help parents develop coping skills and
deal with guilt or anger.
 Early intervention programs for children younger than
age 3 with mental retardation
 Provide day schools to train the child in basic skills, such
as bathing and feeding.
 Vocational training.
M. Sandeep kumar
51

PREVENTION:-
PRIMARY PREVENTION
SECONDARY PREVENTION
TERTIARY PREVENTION
M. Sandeep kumar
52

PRIMARY PREVENTION ………
Preconception:-
 Genetic counseling,
 Immunization for maternal rubella.
 Blood tests for marriage licenses can identify the presence of venereal
disease.
 Adequate maternal nutrition can lay a sound metabolic foundation for later
childbearing.
 Family planning in terms of size, appropriate spacing and age of parents can
also affect a variety of specific causal agents.
M. Sandeep kumar
53

PRIMARY PREVENTION ……
During gestation:-
 Prenatal care:-
 Adequate nutrition, fetal monitoring and protection from diseases.
 Avoidance of teratogenic substances like exposure to radiation and
consumption of alcohol and drugs.
 Analysis of fetus for possible genetic disorder:-
 By amniocentesis, fetoscopy, fetal biopsy and ultrasound.
M. Sandeep kumar
54

PRIMARY PREVENTION ………
At delivery:-
 Delivery conducted by expert doctors and staff, especially in cases
of high risk pregnancy.
 Apgar scoring done at 1 to 5 minutes after the birth of the child.
 Injection of gamma globulin, to protect the child not to get Rh-
incompatability.
M. Sandeep kumar
55

PRIMARY PREVENTION ……
Childhood:-
 Proper nutrition throughout the developmental period and
particularly during the first 6 months after birth.
 Dietary restriction for specific metabolic disorders until no longer
needed.
 Avoidance of hazards in the child’s environment to avoid brain
injury from causes such as lead poisoning, ingestion of chemicals,
or accidents.
M. Sandeep kumar
56

SECONDARY PREVENTION……
 Early detection and treatment of preventable disorders. For example
phenylketonuria, hypothyroidism can be effectively treated at an early
stage by dietary control or hormone replacement therapy.
 Early recognition of presence of mental retardation. A delay in
diagnosis may cause unfortunate delay in rehabilitation.
 Psychiatric treatment for emotional and behavioral difficulties.
M. Sandeep kumar
57

TERTIARY PREVENTION……
 This includes rehabilitation in vocational, physical and social
areas according to the level of challenged.
 Rehabilitation is aimed at reducing disability and providing
optimal functioning in a child with mental retardation.
M. Sandeep kumar
58

CARE AND REHABILITATION OF MR
 The prevention and early detection of mentally handicaps.
 Regular assessment of the mentally retarded persons attainments and
disabilities.
 Advice, support, and practical measures for families.
 Provision for education, training, occupation, or work appropriate for
each handicapped person.
 Housing and social support to enable self-care.
 Medical, nursing, Psychiatric and psychological services those who
require them as outpatients, day patients or inpatients.
M. Sandeep kumar
59

GENERAL PROVISIONS……
 The family doctor and pediatrician are mainly responsible for
early detection and assessment of mental retardation and
assessment of mental retardation.
 The team providing continuing health care also includes
psychologists, speech therapists, nurses, occupational
therapists and physiotherapists.
M. Sandeep kumar
60

Mildly retarded….
 A few mildly retarded children require fostering, boarding
schools placement or residential care, but usually specialist
services are not required.
 Mildly retarded adults may need help with housing,
employment or with the special problems of old age.
M. Sandeep kumar
61

Severely retarded……..
 In case of severely retarded may require special services throughout
their lives, which may include a setting services, day respite during
school holidays, or overnight stays in a foster family or residential care.
 The main principle now guiding the provision of resources is that the
retarded person should be use the usual community services rather than
to provide specialist segregate services.
M. Sandeep kumar
62

Education and training…….
 The aim is that as many mentally retarded children as possible are
educated in ordinary schools either in normal classes or in special
classes.
 There is now an increasing use of more specialists teaching and a variety
of innovative procedures for teaching language and other methods of
communication.
 Before leaving school, these children require reassessment and
vocational guidance.
M. Sandeep kumar
63

HINTS FOR SUCCESSFUL TRAINING…
 Divide each training activity into small steps and demonstrate.
 Give repeated training in each activity.
 Give the training regularly and systematically.
 Starts the training with what the child already knows and then proceed to the
skill that needs to be trained. By this the child will have a feeling of success
and achievement.
 Rewards his efforts even if the child attains near success.
 Use the training material which is appropriate, attractive and locally
available.
M. Sandeep kumar
64

HINTS FOR SUCCESSFUL TRAINING…
 Remember children will learn better from children of the same
age.
 Remember there is no age limit for training a mentally retarded
person.
 Assess the child periodically preferably once in a four or six
months.
 Remember a mentally retarded child learn very slowly. Tell the
parents not to be dejected at the slow progress, nor feel threatened
M. Sandeep kumar
65

VOCATIONAL TRAINING………
 Vocational activities include in vocational training are work
preparation, selective placement, post placement and follow
up. For example:- MITRA special school and vocational
training center for the mentally retarded , Bengaluru,
Karnataka.
M. Sandeep kumar
66

HELP FOR FAMILIES……..
 Help for families is needed from the time that the diagnosis is first made.
 When the child starts school the parents should not only be kept
informed about this progress, but should feel involved in the planning
and provision of care.
 Families are likely to need extra help when their child is approaching
puberty or leaving school.
 Stages in parent counseling…
M. Sandeep kumar
67

Stages in parent counseling…..
 Stage-I:- impart information regarding condition of the mentally retarded
child. Avoid giving misleading information or building false hopes in the
parents.
 Stage-II:- help the parents develop right attitude towards their mentally
retarded child (to prevent overprotection, rejection, pushing the child too
hard). Handle guilty feelings in parents.
 Stage-III:- create awareness in parents regarding their role in training
the child.
M. Sandeep kumar
68

Can I ask some questions…..?
 Is mental retardation same as mental illness?
 No , mentally retarded persons are not mentally ill. The mentally retarded
persons are just slow in their development.
 Is mental retardation curable?
 No. mental retardation is a condition which cannot be curable. But timely and
appropriate intervention can help mentally retarded person learn several skills.
 Is it true that the mentally retarded persons cannot be taught anything?
 No. mentally retarded persons can be taught many things, but they need to be
trained systematically. They can perform many jobs under supervision.
M. Sandeep kumar
69

 Can marriage solve the problems of mentally retardation?
 No. many people think that after marriage, the mentally retarded
person will become active and responsible or sexual satisfaction will
cure the person. That is not so. Marriage will only further complicate
the problem. When it is known that a mentally retarded person
cannot be totally independent, it will not be possible to look after his
family.
M. Sandeep kumar
70

 Do mentally retarded persons become normal, as they grow older ?
 No. the mentally retarded persons mental development is slower than
that of a normal person. Therefor when their actual age increases with
time, the mental development does not occur at the same pace to catch
up with the actual age.
 Is mental retardation an infectious disease?
 No. Interaction between mentally retarded children and normal children
on the other hand, helps in the improvement of mentally retarded
children.
M. Sandeep kumar
71

NURSING MANAGEMENT:-
Assessment:-
 Assessment of early infant behavior for cognitive disability include non-responsiveness to
contact, poor eye contact and during feeding, slow feeding, diminished spontaneous activity,
decreased responsiveness to surroundings, decreased alertness to voice or movement, and
irritability.
 Documentation of daily living skills.
 A careful family assessment for information on
 The family’s response to the child.
 Presence of other members with impaired cognition in the family.
 Degree of independence encouraged at home.
 Stability of the family unit.

INTERVENTION:-
 The long term goals for these children are highly individualized and are
dependent on the level of mental retardation . parents should be involved in
establishing realistic goals for their child. Some of these goals can be:
 The child dresses himself
 The child maintains continence of stool and urine
 The child demonstrate acceptable social behavior
 The adolescent participates in a structured work program.
M. Sandeep kumar
73

 Early intervention programs are essential to maximize the potential
development.
 The nurse can participate in programs that teach infant stimulation, activities of
daily living and independent self-care skills. A successful technique in treatment
of the mentally retarded is called operant conditioning.
 In addition learning social skills and adaptive behavior assists the child in
building a positive self-image. For older children and adolescent assistance
is needed to prepare them for a productive work life.
M. Sandeep kumar
74

MR REHABILOITATION CENTERS IN INDIA ……..
 V.D. Indian Society for mentally retarded. Mumbai
 The Association for the Welfare of Persons with a Mental Handicap in
Maharashtra (A.W.M.H. Male). Mumbai 400 023
 NATIONAL INSTITUTE OF MENTALLY HANDICAPPED has three regional centers
located at New Delhi, Kolkata, & Mumbai,
 MITRA special school and vocational training center for the mentally retarded ,
Bengaluru, Karnataka.
M. Sandeep kumar
75

MR REHABILOITATION CENTERS IN AP……..
1. Thakur Hari Prasad Institute of Research & Rehabilitation for the Mentally
Handicapped, Hyderabad .
2. National Institute for the Mentally Handicapped Manovikas Nagar,P.O.
Secunderabad .
3. RASS College of Special Education, Rashtriya Seva Samiti, Seva Nilayam,
Tirupati .
4. B.S.R. College of Special Education for Mentally Retarded, Anantapur.
M. Sandeep kumar
76

M. Sandeep kumar
77

PPT ON MENTALLY CHALLENGED CHILDREN OR MENTAL RETARDATION IN CHILDREN

More Related Content

PPT ON MENTALLY CHALLENGED CHILDREN OR MENTAL RETARDATION IN CHILDREN