Psychological intervention may be directed to the parent or family or, with an older child, primarily child-directed. Examples of therapeutic approaches are guidance therapies, such as directive advice giving, counseling to create their own solutions to problems, psychotherapy, behavioral management techniques, psychopharmacologic methods (from a psychiatrist), and cognitive therapy.
Motor intervention may be performed by a physical or occupational therapist. Neurodevelopmental therapy (NDT), the most commonly used method, is based on the concept that nervous system development is hierarchical and subject to some plasticity. The focus of NDT is on gait training and motor development, including daily living skills; perceptual abilities, such as eye-hand coordination; and spatial relationships. Sensory integration therapy is also used by occupational therapists to structure sensory experience from the tactile, proprioceptive, and vestibular systems to allow for adaptive motor responses.
Speech-language intervention by a speech and language therapist/pathologist (oral-motor therapist) is usually part of the overall educational program and is based on the tested language strengths and weaknesses of the child. Children needing this type of intervention may show difficulties in reading and other academic areas and develop social and behavioral problems because of their difficulties in being understood and in understanding others. Hearing intervention, performed by an audiologist (or an otolaryngologist), includes monitoring hearing acuity and providing amplification when necessary via hearing aids.
Social and environmental intervention generally includesnursing or social work involvement with the family. Frequently the task of coordinating services falls to these specialists. Case managers may be in the private sector, fromthe child’s insurance or Medicaid plan, or part of a childprotection agency.
Medical intervention for a child with a developmentaldisability involves providing primary care as well as specific treatment of conditions associated with the disability.Although curative treatment often is not possible, functionalimpairment can be minimized through thoughtful medicalmanagement. Certain general medical problems are foundmore frequently in delayed and developmentally disabledpeople (Table 10-5), especially if the delay is part of a knownsyndrome. Some children may have a limited life expectancy.Supporting the family through palliative care, hospice, andbereavement is another important role of the primary carepediatrician.
SELECTED CLINICAL PROBLEMS: THE SPECIAL NEEDS CHILD
MR is defined as significantly subnormal intellectual functioning for a child’s developmental stage, existing concurrently with deficits in adaptive behaviors (self-care, home living, communication, and social interactions). MR is defined statistically as cognitive performance that is two standard deviations below the mean (roughly below the 3rd percentile) of the general population as measured on standardized intelligence testing. The last known estimate of the prevalence of MR is that about 2% of the U.S. population is affected. Levels of MR from IQ scores derived from two typical tests are shown in Table 10-6. Caution must be exercised in interpretation because these categories do not reflect actual functional level of the tested individual.
The etiology of the central nervous system insult resultingin MR may involve genetic disorders, teratogenic influences,
Mild 50–69 50–55 to 70 Educable mentally retarded (EMR)
Moderate 35–49 35–40 to 50–55 Trainable mentally retarded (TMR)
Severe 20–34 20–25 to 35–50
ICD-10, International Classification of Diseases (WHO), ed 10; WISC-IV, Wechsler Intelligence Scale for children, ed 4.