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RISK FACTOR MILD MENTAL RETARDATION IN EXTRAORDINARY SCHOOL AT SURABAYA

Background: Children with mild mental retardation tend to have late language skills so that it affects aspects of speech and independence and can persist into adulthood. Knowing the risk factor of mental retardation is important because disability in children can be prevented by knowing the cause. Objective: This study aims to analyze risk factors for students with mild mental retardation in special schools in Surabaya in the academic year 2019-2020. Methods: This study was an observational analytic study with a case-control approach that took primary data in the form of a questionnaire on parents. Then the data is analyzed through univariate to display the characteristics of respondents and descriptive research variables and bivariate analysis with a chi-square test to determine the effect of risk factors on mental retardation. Results: In this study, there was a total of 100 samples after being excluded from 192 samples. Factors obtained by the length of neonatal stay in the hospital (p=0.010, OR=0.318, 95%CI=0.1310.775), baby cries immediately at birth (p=0,000, OR=0.052, 95%CI=0,007-0,417), antenatal care (p=0.014, OR=0.107, 95%,CI=0.013-0.889), LBW (p=0.002, OR=0.820, 95%CI=0,72000,934), prematurity (p=0,007, OR=0,148, 95%CI=0,031-0,706), family income (p=0,000, OR=0.077, 95%CI=0.028-0.207), father's education (p=0.001, OR=5.310, 95%CI =1,913 14,745) affect mild mental retardation. Conclusion: Factors that influence mild mental retardation consist of perinatal factors (baby crying at birth) and environmental factors (family income and father's education).


INTRODUCTION
Mild Mental Retardation is defined as a child with an IQ range of 69 until 50. Language skills tend to be late which affects the aspects of speech and independence and can settle into adulthood [1]. According to the 2017 Global Burden of Disease data, the prevalence of mental retardation in the world in 2007-2017 increased by 12.9% and still numbered 188,585 in 2017 [2]. According to Pendataaan Program Perlindungan Sosial (PPLS) in 2011, the number of children with mental retardation was 30,460 children out of a total of 130,572. This data is spread throughout Indonesia with the most provinces in Central Java, East Java, and West Java [3]. Based on etiology or direct causes, mental retardation can be divided into psychosocial or socio-cultural and biological causes [4]. The inclusion criteria in the case group in this study were parents of students with mild mental retardation in the Surabaya Extraordinary School and in the control group of parents of students with normal IQ in Surabaya Elementary School who were less than 18 years old and were willing to contribute to the study. While the exclusion criteria in this study were incomplete data on the history of pregnancy and IQ from students in the case and control groups.
The instrument in this study uses primary data in the form of a questionnaire containing risk factors for mild mental retardation with research variables consisting of maternal age during pregnancy, family history of mental retardation and history of maternal immunization, consumption of herbal medicine, the length of neonatal stay in the hospital, history of childbirth, baby cries immediately at birth, antenatal care, alcohol consumption, TORCH infection during pregnancy, maternal disease during pregnancy, prematurity, addiction to narcotic drugs, being in a smoker's environment, LBW, the psychological disorder of the mother during pregnancy and pregnancy complication, parents education, family income and stimulation of caregiver's every day according to age groups and secondary data in the form of IQ.

RESULT
The number of respondents in students with mild mental retardation in Surabaya was 121. 50 respondents were included in the inclusion criteria in this study. A total of 71 respondents were excluded, with details 33 having no data on IQ and 38 with incomplete pregnancy history. While the number of respondents in students with normal IQ in SD Surabaya was 70.
After inclusion and exclusion criteria, 50 respondents were included in the study. A total of 20 respondents were excluded because they did not have a complete history of pregnancy.
The results of the study found that the average IQ in 50 students with mild mental retardation was 62, while in 50 students with a normal IQ was 119. The analysis in this study was done in a descriptive or univariate way to display the characteristics of respondents and bivariate analysis using crosstabs to find out the value p or significance of risk factors causing mild mental retardation with the chi-square test using

History of maternal TT immunization
The results obtained in this study indicate that maternal TT immunization history is not at risk for mild mental retardation. The toxin in tetanus bacteria can inhibit synapse inhibitors in infected newborns that can also cause apnea, hypoxia, and seizures in periods of susceptible brain growth and development which can lead to intellectual disability [11].
According to the 2012 SKDI, 45 percent of mothers received two or more TT immunizations during the last pregnancy, with 60 percent of children at birth during the last 5 years receiving protection from tetanus during the neonatal period [5]. The high immunization rate in Indonesia causes the immunization history factor to not affect mild mental retardation.
The same results were obtained in a study conducted by Nemerimana, Chege, and Odhiambo (2018) which stated that neonatal infection had no effect on the incidence of mental retardation with p-value = 0.471 [12].

Consumption of herbal medicine
In this study, the consumption of herbal medicine did women, only 7 consumed herb to overcome complications in their pregnancy [5]. This shows that the factor of consumption of herb and herbal medicine has no effect on mild mental retardation due to the low consumption of herb in pregnant women and it is recommended not to be consumed by the government in antenatal services.
In a study conducted by Purnamawati [16]. It is caused by the activation of microglia in the brain which causes oxidative stress, blood-brain barrier dysfunction, and migration of leukocytes which can cause damage to brain cells [17].
Different results were found in research conducted by Nemerimana, Chege, and Odhiambo (2018) which stated that neonatal infection had no effect on the incidence of mental retardation with a value of p = 0.471 [12], however, mild mental retardation has not been studied.

History of childbirth
There was no influence between the history of childbirth and the incidence of mild mental retardation in this study. According to data from the Ministry of Health in the

Baby cries immediately at birth
In this study, the baby cries immediately at birth are the most influential factors of causing mild mental retardation.
Babies who cry immediately at birth indicate an active respiratory system which is influenced by physical stimulation factors, carbon dioxide accumulation as well as lack of oxygen and chest compressions [21]. If the baby does not cry immediately, it can lead to asphyxia or systemic hypoxia and decreased blood flow to the brain. Symptoms such as abnormal movement and muscle tone may be present, sometimes resulting in persistently low APGAR scores or a diagnosis of neonatal encephalopathy (hypoxic-ischemic encephalopathy) if it has caused severe brain damage. a mechanism of decreasing blood flow to the brain which will result in a decrease saturation of oxygen and glucose so that anaerobic metabolism will occur [23]. Lactate production will increase, resulting in increased oxidative stress which will cause microvascular damage, cerebral edema, and ischemia which leads to brain cell death. The sodium and potassium pumps also do not run, resulting in depolarization and influx of sodium, an increase in intracellular calcium which will result in various other mechanisms that lead to the death of brain cells [24]. Asphyxia that occurs in the hippocampus can result in decreased cognitive function [22]. In antenatal care, sexually transmitted diseases, preeclampsia, and HIV were screened and conditions such as premature babies and neonatal sepsis can be prevented. Other preventive measures such as tetanus toxoid immunization, iron supplementation to prevent iron anemia and folic acid can also be done [28]. A study conducted by Chavan and Rozatkar, 2014 states that mental retardation can be prevented by antenatal screening such as down syndrome, other genetic disorders, and defects in neural tubes [29]. Failure to do so increases the risk of a low birth weight baby, which can lead to mental retardation [30]. In a study conducted by Mantao and Suja (2018), it was stated that maternal adherence to antenatal care was lower in rural areas than in urban areas. Maternal education level has a significant effect on urban ANC compliance (p<0.05), while in rural areas, maternal education level is not related to ANC compliance (p>0.05) with the highest education level being SMP-SMA [31]. In this study, which is located in Surabaya, an urban area with an average high school level of maternal education, according to the study conducted, many pregnant women do not comply with antenatal care because of their lack of education, which has an impact on the incidence of mild mental retardation.
The results of this study are not following the research conducted by Nemerimana, Chege, and Odhiambo in 2018 in Kenya, Africa which stated that antenatal care has an influence on mental retardation with a value of p = 0.256 [12], but factors regarding mild mental retardation have not been studied.

Alcohol consumption
In this study, there was no effect between alcohol intoxication and mild mental retardation because only 1 in 100 pregnant women consumed alcohol. The prevalence of women who drink alcohol in Indonesia is only around 0.4% [32].

TORCH infection during pregnancy
The results obtained in this study show that infection during pregnancy is not a risk of mild mental retardation.
Prevention of infection has been implemented in antenatal services included in the 10T, one of which is advising pregnant women to carry out routine and special laboratory tests and IEC according to the problem. The role of health workers in early detection of TORCH infection in pregnancy is considered good [34].

Prematurity
Prematurity affects mild mental retardation in this study. Olivieri et al.,2012 in their study stated that cognitive function in preterm infants is lower than full-term infants [35]. This can be caused by an increase in the incidence of infection that occurs in premature infants due to the body's function of reducing infection in cellular immunity that is not functioning properly or cannot withstand the adaptive immunity specific antigen can be produced [36]. Decreased connectivity and a less complex brain compared to term infants can lead to a lower IQ leading to progressively impaired maturity of cognitive function [37].
Corcoles-Parada et al.,2019 in a study with CT-Scan in children aged 8-16 years with a history of premature found that they have a thin cortical thickness in several areas of the cortex which can cause a low IQ. Also, the gray matter was found to have significant changes in fractional anisotropy and radial diffusivity (p <0.05) [38].
Invasive procedures at the NICU such as skin prick blood sampling, endotracheal suction, and intravenous cannula insertion are frequently performed in preterm and low birth weight neonates. The results of the study suggest that the procedure can increase the radial diffusion rate at age 7 years of age which is suspected of causing abnormal myelination reduction in the superior grisea substance and is associated with decreased IQ in these children. The relationship between the number of procedures performed, brain microstructure damage, and IQ is driven by two frontoparietal functions, namely for language and memory storage for work which has the same neural substrate [39].
In a study conducted by Volpe, 2009, state there are two possible combination mechanisms that damage the brain, namely trophic or maturational. The type of primary brain injury that occurs usually consists of periventricular leukomalacia, a typical form of grisea substantial injury to the brain which is often accompanied by neuronal or axonal disease and affects the grisea substance of the brain, thalamus, basal ganglia, cerebral cortex, brainstem, and cerebellum. This difference in neuronal/axonal concentration and periventricular leukomalacia can be referred to as encephalopathy due to prematurity which affects cognitive function [40].
The same results in this study were also found in a study conducted by Heuvelman et al.,2018 which examined the factor of gestational age in children with mental retardation without genetic factors in Sweden. The study stated that gestational age, especially prematurity, was associated with the incidence of mental retardation with a p-value <0.001 [41]. In a study conducted by Purwiyanti, Soemanto, and Dewi (2017) in Purwokerto also showed the same results where mental retardation was influenced by prematurity factors with a pvalue <0.001 [8].

Low Birth Weight
In this study, factors of low birth weight affect mild mental retardation. Immaturity of respiratory organs, nervous system, brain damage in neonates (cerebral palsy, hydrocephalus, hypoxic-ischemic encephalopathy), and other complications of birth caused by low birth weight can also result in impaired cognitive function [42]. Reduced longdistance brain connectivity is also seen in the cortico-basal ganglia, especially in the prefrontal and limbic areas that affect neurobehavioral disorders such as hyperactivity or deficits in RISK FACTOR MILD MENTAL RETARDATION IN EXTRAORDINARY SCHOOL AT SURABAYA JPS | 2020, 09 (02) 42 cognitive function, especially executive function at school age. There was also a reduction in head circumference [43]. In a study conducted by Yaqoob et a.l, it was 2004 stated that head circumference at birth had an effect on mild mental retardation with a value of p = 0.28733 [7].
The total number and volume of the grisea substansia in the brain, the volume of the cerebellum and hippocampus, the total number of cells in the brain, the content of myelin, the thinning of the cortex with changes in gyrification and delayed myelination. Impaired brain connectivity is evidenced by deficits in neuron migration, reduced dendritic processes, and less efficient networking with long-distance connections [43].
The same result in this study was found in the research of Purwiyanti, Soemanto, and Dewi (2017)

Being in a smoker's environment
There is no effect between smoking and the incidence of mild mental retardation in this study. Smoking prohibition is also found on packs and is regulated in UU no. 81 the year 1999 concerning safeguarding cigarettes for health because it can cause fetal problems. The same results were found in a study conducted by Nemerimana, Chege, and Odhiambo (2018) that pregnant women who lived in smokers did not affect mental retardation with OR = 0.18; 95% CI: 0.06-0.55; p = 0.001 [12].

Father's education
Risk factors for father's education affect mild mental retardation. This is per data conducted by the Ministry of Health, 2012 on the SDKI which states that 26% of married men have graduated from high school [5]. Following this study where the respondents in the case and control group mostly graduated from high school. The middle to lower economic level that most respondents, amounting to 2,008 out of 9,306 in the 2012 SDKI also affects the level of education.
Where a high economy is also in line with the possibility of getting a better education as well. A bad environment such as high exposure to plumbum substances in a low economy can result in oxidative stress which damages cellular components, causing academic disruption in children [44]. Emerson, Graham, and Hatton (2006) stated that there is a relationship between parental education and family opinion that affects the development of the cognitive function of children [45]. Also, parental education influences the relationship between parents and children, including providing stimuli for child development, such as neurological, linguistic, socio-emotional, motor, and developmental functions.
Permissive parenting was found mostly in mild mental retardation in RSUD Dr. Soetomo, where children should not be too freed but not always demanding. [46]. Therefore, parents with low education need special programs to study child development [47].
Different results were found in the study conducted by Yaqoob et al. (2004) in Pakistan, where the level of education of the father did not have a significant effect with p-value <0.1489 [7]. The different results were due to the higher education level in the control group studied than the case group, unlike this study where the education of fathers in the case group was lower than the control group.

Mother's education
The results obtained in this study indicate that parental education does not affect mild mental retardation. In this study, it was found that the average mother in high school education, following the minimum standards of compulsory education in Indonesia, UUD 45-chapter XIII, article 31, paragraph 1 concerning the national education system. This causes maternal education to not affect mild mental retardation.
However, the results of this study contradict the study conducted by Yaqoob et al. (2004) in Pakistan which stated that maternal education has an effect on mild mental retardation with a value of p <0.005 [7], due to the large number of mothers who are not in school and different countries where Pakistan is the second-highest dropout rate in the world [48].

Family income
The results obtained in this study also affect mild mental retardation. Income affects the education level of parents, increases the incidence of divorce, and status as a minority has a cumulative effect on children's health and disabilities.
Children born to parents with low income are also more likely to be born prematurely, poor birth output, developmental disabilities, serious chronic illnesses with complications, poor access to health facilities, insufficient nutrition, possibly depressed parents toxic stress in children [49]. Low JPS | 2020, 09 (02) 43 socioeconomic factors are the root of various biological and environmental problems that can cause mild mental retardation.
In contrast to research conducted by Purwiyanti, Soemanto, and Dewi., 2017 which states that there is no relationship between family income and mental retardation with OR = 1.04, 95% CI = 0.52-2.10, but the effect of mild mental retardation has not been studied. [8]. In a study conducted by Lakhan, 2015 in India, parents with low socioeconomics tended to have a relationship with mild (p = 0.204), moderate (p = 0.652) and severe (p = 1.00) mentally retarded children, while children with mental retardation very heavy and borderline tend to be associated with higher economies [9].

Research Limitations
In the execution carried out in this study, the obstacles that were found by the researchers were the incomplete IQ and pregnancy data resulting in the number of samples being minimal.

CONCLUSION
The results in this study found no correlation between mild mental retardation and prenatal factors. Perinatal factors that consist of the length of neonatal stay in the hospital, baby cries immediately at birth, antenatal care, prematurity, LBW and environmental factors consisting of family income and father's education affect mild mental retardation.