HOW TO TREAT MENTAL RETARDATION (INTELLECTUAL DEVELOPMENTAL DISORDER) 2025

HOW TO TREAT MENTAL RETARDATION (INTELLECTUAL DEVELOPMENTAL DISORDER) 2025

GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF COMMON MENTAL DISORDERS

(Enacted under Decision No. 2058/QĐ-BYT dated May 14, 2020, by the Minister of Health)

Article 28

MENTAL RETARDATION

(INTELLECTUAL DEVELOPMENTAL DISORDER)

CHIEF EDITOR

Associate Professor, PhD Nguyễn Trường Sơn

CO-EDITOR

Associate Professor, PhD Lương Ngọc Khuê

PhD Nguyễn Doãn Phương

CONTRIBUTING AUTHORS

PhD Trần Thị Hà An

MSc Trịnh Thị Vân Anh

PhD Vũ Thy Cầm

MSc Trần Mạnh Cường

PhD Nguyễn Văn Dũng

PhD Vương Ánh Dương

PhD Lê Thị Thu Hà

MSc Trần Thị Thu Hà

MSc Phạm Công Huân

MSc Đoàn Thị Huệ

Specialist Doctor II Nguyễn Thị Minh Hương

MSc Vũ Thị Lan

1. Nguyễn Phương Linh

Specialist Doctor II Nguyễn Thị Phương Loan

MSc Bùi Văn Lợi

MSc Nguyễn Thị Phương Mai

PhD Trần Nguyễn Ngọc

MSc Bùi Nguyễn Hồng Bảo Ngọc

MSc Trương Lê Vân Ngọc

MSc Bùi Văn San

PhD Dương Minh Tâm

MSc Phạm Xuân Thắng

MSc Lê Thị Phương Thảo

MSc Lê Công Thiện

MSc Vương Đình Thủy

Associate Professor, PhD Nguyễn Văn Tuấn

Specialist Doctor II Ngô Văn Tuất

MSc Đặng Thanh Tùng

MSc Vũ Sơn Tùng

MSc Cao Thị Ánh Tuyết

MSc Nguyễn Thị Ái Vân

Specialist Doctor II Hồ Thu Yến

MSc Nguyễn Hoàng Yến

CONTRIBUTORS TO EVALUATION AND FEEDBACK

Associate Professor, PhD Nguyễn Thanh Bình

PhD Vũ Thy Cầm

PhD Nguyễn Hữu Chiến

Specialist Doctor II Võ Thành Đông

PhD Lê Thị Thu Hà

Specialist Doctor II Đỗ Huy Hùng

PhD Nguyễn Mạnh Hùng

MSc Nguyễn Trọng Khoa

Specialist Doctor II Ngô Hùng Lâm

Associate Professor, PhD Phạm Văn Mạnh

Specialist Doctor II Trần Ngọc Nhân

PhD Dương Minh Tâm

MSc Đặng Duy Thanh

PhD Vương Văn Tịnh

Specialist Doctor II Lâm Tứ Trung

PhD Lại Đức Trường

PhD Cao Văn Tuân

Associate Professor, PhD Nguyễn Văn Tuấn

SECRETARIAT TEAM

MSc Đặng Thanh Tùng

MSc Trương Lê Vân Ngọc

BA Đỗ Thị Thư

Article 28

MENTAL RETARDATION

(INTELLECTUAL DEVELOPMENTAL DISORDER)

I. DEFINITION  

Mental retardation, or intellectual developmental disorder, is a condition characterized by arrested or incomplete mental development, primarily marked by deficits in skills during developmental periods, including cognitive, language, learning, occupational, social, and self-care abilities. Its prevalence in the general population ranges from 1-3%. It may or may not be accompanied by other physical or psychiatric disorders.

II. ETIOLOGY  

Causes are categorized into four groups based on their timing of impact on child development, from embryonic stages to early years:  

1. Genetic Factors: Chromosomal and genetic abnormalities (e.g., Down syndrome, congenital brain malformations).  
2. Prenatal Factors:

   – Maternal infections during pregnancy (e.g., influenza).  

   – Toxemia, drug/alcohol/stimulant exposure.  

   – Maternal conditions affecting the fetus (e.g., hyperthyroidism, hypothyroidism, Rh incompatibility).  

3. Perinatal Factors:  

   – Premature birth, asphyxia.  

   – Obstetric interventions causing brain injury (e.g., forceps, vacuum extraction).  

4. Postnatal Factors:  

   – Neurological infections (e.g., encephalitis, meningitis).  

   – Malnutrition, cranial deformities, traumatic brain injury.  

   – Inadequate psychosocial environment or education.  

   – Metabolic disorders (e.g., phenylketonuria), epilepsy, hypothyroidism.  

– In some cases, particularly mild forms, no clear cause is identified.

III. DIAGNOSIS  

1. Definitive Diagnosis (ICD-10)  

1.1. Clinical Features  

– Mild Mental Retardation (F70):  

  – Cognition: Concrete descriptive thinking, poor abstract reasoning, limited initiative, weak analysis/synthesis skills. Delayed speech but capable of daily communication and basic writing.  

  – Education: Can complete primary school but often repeats grades, struggles with theoretical learning.  

  – Emotions: Higher emotions present but lacks independence, remains reliant on parents into adulthood, struggles with internal conflicts.  

  – Behavior: Self-care capable, can perform simple tasks, adapts to social settings with assistance but less efficiently than peers.  

  – IQ: 50-69.  

– Moderate Mental Retardation (F71):  

  – Cognition: Rudimentary general thinking, no abstract reasoning, poor grasp of core issues, limited judgment, no independent thought. Basic concrete arithmetic possible, no abstract calculation. Delayed speech/hearing comprehension, limited vocabulary, simple grammar, mispronunciation, stammering, or articulation issues. Uses language for communication but lacks social nuance understanding. Writing difficult to develop.  

  – Emotions: Unstable, limited higher emotions.  

  – Behavior: Can perform simple tasks but not procedural/mechanical work, inflexible to change. Rarely fully independent, requires guidance.  

  – IQ: 35-49.  

– Severe Mental Retardation (F72):  

  – Cognition: Basic concrete thinking, learns simple experiences. Minimal or no language, may produce simple sounds without comprehension.  

  – Emotions: Instinctual emotions only, self-focused satisfaction, rudimentary expression.  

  – Behavior: Instinctual actions or basic responses to external stimuli. Requires assistance for self-care. Often accompanied by physical/psychiatric conditions.  

  – IQ: 20-34.  

– Profound Mental Retardation (F73):  

  – Cognition: No cognitive ability, no response to basic stimuli (e.g., heat/cold), no language.  

  – Emotions: Purely instinctual, with outbursts of anger, self-harm, or aggression.  

  – Behavior: Poor motor skills, may be immobile, repetitive stereotyped actions. Frequently accompanied by multiple physical/neurological/psychiatric conditions.  

  – IQ: <20.  

– Other Mental Retardation (F78):  

– Unspecified Mental Retardation (F79):  

2. Ancillary Testing  

– Basic Labs:  

  – Blood: Hematology, biochemistry, microbiology.  

  – Thyroid, sex, and growth hormones (to assess consequences).  

  – Urine analysis.  

  – Metabolic tests for suspected metabolic causes.  

– Imaging/Functional Tests:  

  – Chest X-ray, abdominal ultrasound, transcranial Doppler, thyroid ultrasound.  

  – EEG, ECG, cerebral blood flow, polysomnography, CT/MRI brain.  

– Psychological Assessments:  

  – Intelligence tests (e.g., WISC, Raven, Denver).  

  – Tests for co-occurring conditions (e.g., depression, ADHD, autism).  

– Collaboration: Coordinate with other specialties for differential diagnosis.

2. Differential Diagnosis  

– Environmental Deprivation: Normalizes with early intervention, unlike fixed deficits in mental retardation.  

– Chronic Physical Illness/Malnutrition: Causes sluggishness, poor memory, slow learning, but reversible with treatment.  

– Sensory Impairments: Blindness, deafness, mutism.  

– Other Psychiatric Disorders: Autism, schizophrenia.

IV. TREATMENT  

1. Treatment Principles  

– Based on assessing social, educational, psychiatric, and environmental needs.  

– Long-term treatment requiring family and community involvement.  

– Combined treatment for co-occurring psychiatric conditions.

2. Treatment Framework  

– Use educational methods and psychotherapy.  

– Pharmacotherapy for emotional/behavioral symptoms and comorbidities.  

– Long-term family/community support and monitoring.

2.1. Educational Methods  

– Severe/Profound Levels: Managed in specialized medical-educational centers or schools.  

– Mild/Moderate Levels: Comprehensive programs for adaptive, social, and vocational skills to enhance independence.  

  – Content: Daily living skills (personal hygiene, household tasks, greeting adults, following rules), basic literacy (writing, simple arithmetic), vocational training (simple tasks to boost confidence and independence).  

  – Approach: Visual aids, practical simulations.

2.2. Behavioral Therapy  

– Long-term therapy to reinforce social behaviors and reduce aggression/disruption.

2.3. Family Therapy  

– Educate families to enhance patient competence/confidence, provide knowledge on causes, treatment, and care.  

– Support family members in expressing frustration and receiving counseling.

2.4. Other Psychotherapies  

– Music, art, sports, occupational, activity, and physical therapies.

2.5. Pharmacotherapy  

– Tailored to individual needs, treating behavioral/psychiatric symptoms similarly to non-retarded patients.  

– Antidepressants: 1-3 agents:  

  – TCAs: Amitriptyline (25-200 mg/day), Clomipramine (50-100 mg/day), Imipramine (150-300 mg/day).  

  – SSRIs: Sertraline (50-300 mg/day), Fluoxetine (20-60 mg/day), Fluvoxamine (50-100 mg/day), Citalopram (20-60 mg/day), Escitalopram (10-20 mg/day), Paroxetine (20-80 mg/day).  

  – SNRIs: Venlafaxine (37.5-225 mg/day), Duloxetine (40-120 mg/day).  

  – NaSSAs: Mirtazapine (15-60 mg/day).  

  – Dopamine-Norepinephrine Reuptake Inhibitors: Bupropion (75-450 mg/day).  

  – Other: Tianeptine.  

– Antipsychotics: 1-3 agents:  

  – Older generation (e.g., Haloperidol, Chlorpromazine) for agitation/behavioral issues, less preferred due to side effects.  

  – Newer generation (e.g., Risperidone, Olanzapine, Quetiapine, Clozapine) preferred:  

    – Haloperidol (5-30 mg/day), Chlorpromazine (25-500 mg/day), Levomepromazine (25-500 mg/day), Sulpiride (25-200 mg/day), Risperidone (1-10 mg/day), Olanzapine (5-30 mg/day), Quetiapine (50-800 mg/day), Clozapine (25-900 mg/day), Aripiprazole (5-30 mg/day).  

– Benzodiazepines: 1 agent (rapid relief of anxiety/tension but risk dependence):  

  – Diazepam (5-30 mg/day or 0.5 mg/kg/day), Lorazepam (1-4 mg/day), Clonazepam (1-8 mg/day), Bromazepam (3-6 mg/day).  

– Other Anxiolytics/Sedatives: Etifoxine, Grandaxin, Zopiclone, Eszopiclone, Melatonin, Hydroxyzine (10-300 mg/day), Propranolol (start 10 mg twice daily, max 80-160 mg/day).  

– Adjunctive: Neuroprotectants (piracetam, citicoline, ginkgo biloba, vinpocetine, choline alfoscerate, cinnarizine, nicergoline), vitamins/minerals.  

– ADHD Comorbidity: Methylphenidate (6-12 years: 18-54 mg/day; >12 years: 18-72 mg/day).  

– Epilepsy Comorbidity: 1 or more anticonvulsants:  

  – Valproate (30-50 mg/kg/day), Carbamazepine (15-20 mg/kg/day), Phenobarbital (3-6 mg/kg/day), Oxcarbazepine (30-46 mg/kg/day), Gabapentin (25-50 mg/kg/day), Lamotrigine (5-15 mg/kg/day), Levetiracetam (40-100 mg/kg/day).  

– Nutrition: Balanced, digestible diet (soft, high-fiber, fruits), hydration, IV support if needed.

V. PROGNOSIS AND COMPLICATIONS  

– Non-progressive condition requiring lifelong treatment, monitoring, and care.  

– Higher psychiatric comorbidity risk than the general population; managing these reduces complications.  

– Elevated physical illness risk; early detection/treatment lowers morbidity/mortality.

VI. PREVENTION  

1. Primary Prevention:  

   – Reduce/eliminate factors harming CNS development: health education, maternal/child protection, avoiding obstetric brain trauma, genetic/family counseling, support for low-income pregnant women/children.  

2. Secondary Prevention:  

   – Early detection/treatment of conditions affecting brain development (e.g., phenylketonuria, hypothyroidism) to shorten disease progression.  

3. Tertiary Prevention:  

   – Minimize adverse outcomes, complications, and sequelae.

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