RESUMO
Intellectual disability (ID) is a condition of limited intellectual and adaptive functioning that occurs before the age of 18 years. For varied reasons, ID is the most forgotten of public health programs. Exact prevalence is unknown, due to the absence of epidemiological research in children and adolescents, which is essential to know the needs of this population. Detection involves identifying children at risk for any type of atypical development with emphasis on language probes and dysmorphic searching, optimally combined with developmental screening tools with proven psychometric properties; training psychologists and health providers such as general practitioners or pediatricians in the first level of attention is needed. The goal of second-level intervention is to diagnose ID with an emphasis on accurate measurement of intellectural coeficcient (IC) and adaptive level, including expanded genetic medical evaluation and assessment of the personal, familiar, and community resources of children with suspected ID. We also recommend the use of existing classifications, employing the World Health Organization (WHO) International Classification of Functioning, Disability and Health, to identify individual and environmental barriers and facilitators and the application of appropriate tests. The overall treatment includes specific medical, psychological and educative & social interventions. Medical intervention also includes pharmacological treatments, especially psychotropic medication, including risperidone, methylphenidate and melatonin. Developing evidence for the use of this medication is provided for challenging behaviors such as aggression, hyperactivity, sleep problems and depression. Psychological help includes psychoeducation and techniques evidence based, such as those derived from applied behavior analysis and cognitive behavior. Its chronic use is discouraged and medication is recommended to be combined with proper behavior management. Early and appropriate education for ID is lacking; which also requires improving access to health services, limiting social exclusion. Enhancing advocacy and promoting the human rights for this population is also needed.
La discapacidad intelectual (DI) alude a una condición limitada del funcionamiento intelectual y adaptativo, que ocurre antes de los 18 años de edad. Por varias razones, la atención a la DI es uno de los programas de salud pública más olvidada. Se desconoce la prevalencia exacta debido a la ausencia de investigación epidemiológica de la discapacidad en niños y adolescentes, la cual es esencial para conocer las necesidades de esta población. La detección consiste en la identificación de niños en riesgo de algún tipo de desarrollo anormal, con énfasis en el sondeo del lenguaje y la búsqueda de dismorfias, combinado con herramientas como los instrumentos de tamizaje del desarrollo psicométricamente fiables. La meta de la intervención en el segundo nivel es diagnosticar la DI con énfasis en una medición precisa del coeficiente intelectual (CI) y el nivel adaptativo, incluyendo una evaluación genética extendida y una valoración personal, familiar y de recursos comunitarios del niño. También se recomienda el uso de las clasificaciones existentes, incluyendo la Clasificación Internacional del Funcionamiento, la Discapacidad y la Salud (CIF), por ser un sistema que identifica barreras y facilitadores individuales y ambientales. El tratamiento de la DI incluye intervenciones de tipo médico, psicológico, educativo y social. La intervención médica incluye el uso de psicofármacos que pueden ser de gran utilidad en el tratamiento de conductas problemáticas (agresión, hiperactividad, problemas de sueño, depresión). Se aconseja combinarlo con técnicas conductuales y desalentar el uso crónico de los mismos. La intervención psicológica incluye técnicas con base científica como las que derivan del análisis conductual aplicado y las de tipo cognitivo conductual. Las intervenciones de tipo educativo tales como la educación temprana y apropiada para niños con DI es un tema pendiente. También es necesario mejorar el acceso a los servicios de salud con el fin de limitar la exclusión social.
RESUMO
resumen está disponible en el texto completo
Summary As the environment is a crucial source in an infant's development, it is important to assess the proximal environment where a variety of social relationships take place. Experiences derived from the home environment allow the specific activities that a child builds actively. These opportunities have an outstanding impact on an infant's development. The home concept and its influence on development led to the discovery and interrelations of several dimensions and today's emphasis relies on identifying the mechanisms of the variability of environment that exert an influence on the variability of development. Under this perspective, at the end of the 1960's the Infant/Toddler HOME Inventory was developed by Caldwell and Bradley. Very soon, Cravioto adapted it for its use in a Mexican population according to the characteristics of typical families and cultural aspects. The purpose of this investigation was to establish the internal consistency of the Infant/Toddler HOME Inventory in the version adapted by Cravioto through the assessment of the precision of its scoring in terms of internal consistency. Cohort: 62 infants and their mothers were contacted in the first 72 hours after delivery through a Research Program from the Child Psychiatry Hospital Dr. Juan N. Navarro (Environmental Modulation of Infancy Development). They were born in two Mexico City hospitals: a state public hospital, Hospital de la Mujer (Women's Hospital) and in the Mother-infant Research Center from the Birth Study Group (CIMIGEN). All of them were low-risk infants who met the criteria for a one year follow up and whose parents gave their informed consent and accepted to be visited at their homes. The distribution of the infants group by sex was: 30 infants (48%) were female and 32 (52%) were male. Families were classified as follows: 72.5% were nuclear and 27.5% were extended. According to their socioeconomic profile, a high relationship was found between income and housing: seven (11.3%) of the highest income families lived in houses or apartments of their own or rented, where there were more rooms than inhabitants, whereas all others were living as follows: crowded houses or apartments (23 families, 37.1%), houses with of only one room (4 families, 6.5%) and the poorest houses with collective bathroom (28 families, 45.2%). All households had electrical lighting and most of them had also drinkable water inside their homes (98.4%); one shared water from a deep pond with their community. Bathrooms were: 35.5% with running water, 59.7% used a bucket for carrying water and 4.8% had latrine. Instrument: The Infant/Toddler HOME Inventory, version adapted by Cravioto, with 62 items in a binary format response was used. Subscale VII, Play Materials, asked about color, size, consistency or texture and type of toys. The instrument is administered by having a person calling the home at a time when the infant is awake and can be observed interacting with the mother or principal caregiver. The internal consistency of the Infant/Toddler HOME Inventory was monthly assessed for each of its subscales and the total scale, until the child's first year of life (12 months), applying Cronbach's alpha. Results showed that alpha coefficient's values higher than 0.60 throughout the 12 months were observed in the VII Play Materials shoed a range of 0.64 and 0.84, and 0.60 and 0.83 for the Total Scale. On the other hand, subscale VI, Physical Environment, showed a less than 0.60 value with an internal consistency coefficient of 0.56 in the first month of life; nevertheless the remaining months had values between 0.60 and 0.70. This was also observed with subscale II, Mental Development and Vocal Stimulation, with a 0.58 value for the first month of life and alpha values between 0.63 and 0.74 for the remaining eleven assessments. Subscale III, Emotional Climate, exhibited seven evaluations in a range between 0.61 and 0.76; this is the second with a 0.61, fourth with 0.69, sixth with 0.76, seventh with 0.67, ninth with 0.63, tenth with 0.69 and eleventh 0.63. Non-acceptable internal consistency, it is less than 0.60 in most of their scorings were observed for the following scales: I. Adult Contact, V. Breadth of Experience. Only in the sixth month's a value of 0.64 was observed, and the rest of scales exhibited a range within a 0.38 as inferior limit and 0.56 superior limit in the former and a 0.65 value in the tenth month and 0.60 in the eleventh. Subscale IV, Avoidance of Restriction, showed the lowest coefficient with values between 0.24 and 0.49. These results suggest that most of the subscales had adequate reliabilities, except for subscales I, Adult Contact; IV, Avoidance of Restriction; and V, Breadth of Experience. The purpose of this study was to evaluate the internal consistency of an instrument which measures the home environment quality in infants during their first year of life. Results showed the Infant/Toddler HOME Inventory had high internal consistency values in the Total Scale. These results are similar to those obtained by Banard, Bee & Hammond with a group of 179 children in Seattle, where they found 0.77 values at fourth months, 0.81 at eight and 0.86 at twelve. Our findings were within a rank of 0.68 and 0.83. Cronbach's alpha value obtained for the different subscales showed intersubscale differences. Subscales II, III, VI and VII showed internal consistency values equal or higher than 0.60 in most of the assessments during the 12 months of life. This implies measurements are precise and reliable when using them in low risk Mexican infants. Lower values found in subscales I, Adult Contact, IV, Avoidance of Restriction and V, Breadth of the Experience, may be due to the low number of items. According to Nunnally and Bernstein, it is recommended that measurements with a low internal consistency should be used with initial, non-crucial decisions, and with temporary and reversible effects susceptible to replication and rectification. It is very important to stress the fact that this Infant/Toddler HOME Inventory version is not comparable with other in the literature because the structure was notably modified. Limitations in this study are not only this modification, but the size sample, and future research efforts should overcome this fact by trying to sample infants from different Mexican regions. This study points out the need to adapt, develop and evaluate psychometrically instruments that measure specific aspects of the environment of infant's homes. Our results may be an initial step for those interested in measurements of Mexican families homes, or in those interested in the Infant/Toddler HOME Inventory as an indicator of the environmental aspects in early infancy.
RESUMO
Antecedentes. Se postula la importancia de las secuelas neurológicas de origen perinatal. Se revisa la definición de secuela, insistiendo en considerarla como un proceso que se desencadena a partir de ciertos factores de riesgo que la condicionan, para poder abordar el problema a partir de los factores de riesgo y establecer pogramas que prevengan los síndromes de parálisis cerebral, retardo mental y alteraciones de conducta. Objetivo. Señalar la insuficiencia de los procedimientos estadísticos descriptivos y univariados, y proponer el empleo de modelos complejos de análisis. Material y métodos. Se presentan algunos datos publicados en la literatura relativos a la frecuencia de presentación de secuelas y finalmente se expone el programa de la Clínica de Neurodesarrollo del Instituto Nacional de Pediatría-Universidad Autónoma Metropolitana, Unidad Xochimilco. Resultados. Mediante los procedimientos estadísticos descriptivos y univariados no se comprueba la asociación entre factores de riesgo como peso, condición al nacimiento, edad gestacional y datos del diagnóstico de la encefalopatía por US cerebral, EEG, potenciales evocados, exploración clínica neurológica y los datos de los casos y desarrollo posterior de secuelas. Con análisis complejos sí se demuestra la asociación y se insiste en que no es directa ni lineal