PART-B
2. Preventive Measures that we are Addressing
are concentrated in the urban areas. Misconceptions, false beliefs and practicesaccentuate the problem.
1.2 Mental Disorders:
WHO experts have reported a prevalence of 13.9% of psychiatricmorbidity in the general population. It is also estimated that 15-20 persons visiting PHC or general practitioner have in fact emotional problems which appear as physical symptoms. Health has been defined not as merely absence of ill health, but as a state of positive well-being, physical, mental and social. Mental health therefore forms an essential part of total health as such and must form an integral part of the health policy.
The various mental disorders are:
1. Acute mental disorders of varying etiology, like acute psychosis (which can become chronic if not detected and treated in time).
2. Chronic mental illness such as schizophrenia, affective psychosis, epileptic
psychosis etc.
3. Emotional illness such as anxiety, hysteria, neurotic depression.
4. Alcohol abuse and drug intake (These areas will be dealt with ingreater details)
Secondary prevention has the prevention of impairment as its target. The agent has already attacked the individual but it has been identified early and measures are taken to reduce the damage. Adequate neo-natal care for the premature baby, the treatment of babies with PKU with aphenylalanine-free diet, and early and effective treatment of menmgitis are all examples.
This involves preventive and curative health measures and effective public education to improve the use of health services.
We should also bear in mind the multiple risk factor model as handicap in children are typically due to multiple causes which are manifested through developmental delays. Psycho- social retardation, for example, has high prevalence among urban-minority, and low income groups. There are many seemingly normal births in this population where there are previous subclinical neurological conditions (associated with malnutrition, for example), which when associated with poor environmental stimulation lead to subnormal intellectual performance. Such combinations of causes are likely to be much more deleterious. Psycho-social causes of handicaps are a complex set of etiologies which include biological factors if they are to be fully understood.
This type of multiple-agent conceptualization is required as the predominanttheoretical basis of a prevention model.
A very recent study reveals that model interventions to improve the developmental outcome, of Low Birth Weight infants did not cause a reduction inthe rate of mental retardation in the population after a 24 year trial period. In contrast reducing the proportionof children living in poverty who are exposed to environmental deprivation significantly decrease (10%) mental retardation at the end of the model's time period.
This study reveals that long-term reduction in the prevalence of MentalRetardation is attainable by modifying public policies that influence children's developmental programmes.
While in principle there is a considerable information to suggest the appropriateness of a multiple causation model, we still do not have any longitudinal systematic tracking data beginning in infancy and extending through school years. Hence, the relative contribution of social, medical and environmental risk factors as causes of particular categorical handicaps remain theoretical. For our discussion the possible preventive causes canbe named as the following.
2.1 Causes of Mental Retardation can be Categorised as:
1. Causes occurring before birth, Genetic & Non-genetic
2. Causes occurring during birth
3. Causes occurring after birth
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2.1.1 Before Birth:
i) Non-Genetic:Infections such as German Measles. Sexually transmitted diseases such as syphilis, HIV, fits, drugs, alcohol consumption, smoking etc.
ii) Genetic factors: Chromosomal disorders (Down Syndrome) which accounts for 30%
of severe mental retardation, fragile-X syndrome withan estimated incidence of 1:2000.
In addition, there are other known disorders with abnormalities of the number of structure of chromosome (1% -4%)and the inborn errors of metabolism. A summation of these causes leads to the conclusion that more than 50% of severe mental retardation is
genetically determined. Tests are available to detect any of these problems
iii) Other risks before pregnancy: Anaemia, kidney diseases, diabetics, mellitus, high B.P., poor nutrition are some risk factors which warrant periodical check-up and care. If the age of the mother is less than 13 or more than 35 years can also cause complications.
Other risk factors are history of miscarriages, still births, inherited conditionsetc.
2.1.2 During Birth:
Problems such as prolonged and difficult labour premature birth, birthasphyxia are responsible for 10 -20%of cases becoming mentally retarded later. Mothers should be advised against drugs, alcohol, cigarettes etc., during pregnancy. Emotional trauma should also be avoided as it is a risk factor. exposure to X-ray, pesticides etc. must also beavoided.
2.1.3 After Birth:
Accidents leading to head injury, infections of brain like meningitis and encephalitis, untreated fits, fusion of sutures of skull, recurring lowering of blood sugar levels and chronic lead poisoning are factors that can damage the growing brain leading to mentalretardation.
Treatment for Rh incompatibility and PKU/Hypothyroidism will prevent retardation. The child should also be protected against environmental deprivation withproper care and adequate food and in an environment love, care and healthy interaction.
The most important message is that treatment is available to prevent most of these incidents. Almost all these programmes are available and accessible barring genetic tests.
What is required is we have to sensitize the health functionaries, and disseminate information at all levels. We need to COMMUNICATE at all levels. In the light of rapid advances in the field of genetics, today we can diagnose with certainty the genetic risk involved andparents at risk can make informed decisions.
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2.2 Secondary Prevention:
Once the child is born retarded the immediate task is early detection and intervention.
Many simple screening tools are available that helps one identifymental retardation on the basis of delays in normal milestones of development. It is easier to find outchildren with moderate, severe and profound retardation because of obvious gross delay inthe development.
Sensitive tools can screen out children with mild delays.
Early detection and correct diagnosis is most important for providing timely earlystimulation, As we all know the chances of optimal improvement is very high during the first few months / years of the baby when there is a plasticity of the brain which can help overcomethe functions
of some of the lost cells.
Training needs to be imparted on early detection to all health personnel. Earlystimulation can also be taught to parents by these functionaries.
With regard to early stimulation we have various models such as the wellknow head start programme of the West started in the early 1960's, portage programme and many other innovative methods adopted by the NGOs. What needs to be conveyed is that we have the technical acumen of prevention, but what is required is mass scale andeffective implementation of the same. Certain issues merit discussion at this point.
a) Most of the early stimulation programmes especially portage relies heavily on home- based training as it should in terms of empowering the parents and properutilisation of the "most potential" human power available. But various experiences have shown that at times it becomes difficult for a poor illiterate mother in a povertystricken nuclear family to carry on home-based training and stimulation programme asboth parents have to struggle for their survival needs all day long having very little time or energy to attend to home-based training. It is in this context the support of a peripatetictrainer and or a 'neighbourhood centre' for day care that needs to be realisticallylooked into.
b) While most of the preventive tasks can well be carried out by the existinghealth staff, we need to have separate personnel at grassroot level to attend to early stimulation programmes of the mentally retarded children. Developing ANMs and other local functionaries and in their absence separate personnel need to be availablefor it (where the NGOs role comes in a big way).
c) Rich resources and effective traditional methods already exist in manyrural communities.
What is required is to put them to a more conscious use. Specialfocus may be given to the interaction between mother and child. The skillsof baby massage handed down from generatio1s of Indian women are some examples. No oneteaches the skills which are appropriate for early intervention. Intervention will be effective and sustainable
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by using the existing traditional methods. Acceptance andassimilation will also be quicker.
This is another area where NGOs can makea considerable contribution.
2.3
Superstitions Beliefs and Misconceptions:
While we concentrate on the
components of prevention, strategies and the messages to be conveyed we have to bear in mind the various
wrong notions prevailing in each region about preventive methods. For e.g. in some places women are prevented from eating leafy vegetable during pregnancy. There is resistance from the community towards immunisation.
Many harmful practices such as putting hot iron rod on some parts of the body to cure internal problems. These issues need to be dealt with carefully on the basis of the prevailing local beliefs, customs and practices.