Prim Care Clin Office Pract

34 (2007) 375–386

Intellectual Disability (Mental

Retardation) in Children
and Adolescents
Helen D. Pratt, PhD*, Donald E. Greydanus, MD
Michigan State University College of Human Medicine,
Pediatrics Program, MSU/Kalamazoo Center for Medical Studies,
1000 Oakland Drive, Kalamazoo, MI 49008-1284, USA

Mental retardation (MR) (current term, intellectual disability [ID]) is a la-

bel used to describe a constellation of symptoms that includes severe deficits
or limitations in an individual’s developmental skills in several areas or do-
mains of function: cognitive, language, motor, auditory, language, psychoso-
cial, moral judgment, and specific integrative adaptive (activities of daily
living) (Appendix 1) [1–14]. Individuals diagnosed with MR/ID will require
various levels of support to learn how to engage in self-care activities, de-
velop healthy reciprocal intimate relationships, obtain appropriate employ-
ment, and acquire other important activities of daily living. Basic skill
attainment may take longer to learn (ie, speaking, walking, and taking
care of personal needs such as dressing or eating). Academic, social, and
self-regulatory functioning may be the most significantly affected areas
[15,16]. The current label suggested for the term mental retardation by The
American Association on Intellectual and Development Disabilities
(AAIDD formerly AAMR) is intellectual disability (ID).
A general description from multiple sources refers to ID as a developmen-
tal, cognitive, or intellectual deficit that: 1) occurs concurrently with deficits
(mild to severe) in adaptive behavior, academic performance, adaptive func-
tioning and 2) is manifested during the developmental period (birth to late
adolescence or before age 18) [15–22].

* Corresponding author.
E-mail address: [email protected] (H.D. Pratt).

0095-4543/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.pop.2007.04.010 primarycare.theclinics.com
376 PRATT & GREYDANUS

Prevalence
ID is the most common developmental disorder. On average, about 1%
of children ages 3 to 10 years have ID. ID is more common in older children
(ages 6–10 years) than in younger children (ages 3–5 years). ID was also
more common in boys than in girls and more common in black children
than in white children [16,17]. As many as three of every 100 people in
the country have ID [17,19,23]. Nearly 613,000 children ages 6 to 21 have
some level of ID and need special education in school [23]. In fact, 1 of every
10 children who need special education has some form of ID [17].

Etiology
Current literature supports that the following represent common causes
of ID: (1) genetic conditions (fragile X syndrome, Down syndrome, certain
infections [such as congenital cytomegalovirus]); (2) problems during preg-
nancy or birth (Cri-du-chat syndrome or Prader-Willi syndrome, fetal alco-
hol syndrome [FAS]); (3) birth defects that affect the brain (such as
hydrocephalus or cortical atrophy [such as asphyxia]) that occur while
a baby is being born or soon after birth; and (4) problems during infancy,
childhood, and adolescence (ie, injury, disease, or a brain abnormality, seri-
ous head injury, stroke, or certain infections such as meningitis) [16,22].
These listed causes are not all inclusive.
Certain causes of ID are preventable, such as FAS, which is prevented by
having pregnant women refrain from drinking alcohol [22]. Another cause
of ID, phenylketonuria (PKU), galactosemia, and congenital hypothyroid-
ism, can be prevented if babies with these conditions begin appropriate
treatment soon after birth [22].

Signs of intellectual disability

Infants and children who have ID diagnosed generally do not reach de-
velopmental milestones within the expected age range for other infants
and children of their same ages and cultural environments (eg, sitting up,
crawling or walking, talking, or using coherent language). Other symptoms
may include cognitive delays, such as problems with short-term memory,
concept formation, understanding social rules or how to solve problems,
using logic, or understanding cause and effect relationships [18].

Diagnosis
The diagnostic criteria for determining the presence of ID requires that
an individual must first, manifest serious to severe deficits in more than
 INTELLECTUAL DISABILITY IN CHILDREN AND ADOLESCENTS 377

one domain of functioning: (1) cognitive, (2) language, (3) self care, (4) mo-
tor, and (5) adaptive–integrative functioning (Appendix 1) [15–23]. Next,
they must obtain a score that is two or more standard deviations (70 or
less) below the mean (100 on most standardized intelligence quotient [IQ]
tests) of at least one standardized intellectual assessment (Box 1) [22–33].

Box 1. Examples of standardized intellectual assessments

Infants
Bayley Scales of Infant and Toddler Development–Third Edition
(Bayley–IIIä) [25] (ages 1 to 42 months)
 Addresses IDEA 2004 regulations thatrequire infants
and toddlers to receive developmental services in the areas
of physical, cognitive, communication, social–emotional,
and adaptive development.
Toddlers
Wechsler’s Pre-school and Primary Scale of Intelligence,
Forth Edition (WPPSI-IVâ) [26] (ages 2 years, 6 months
to 7 years, 3 months)
 Assesses cognitive abilities (verbal, perceptual, working
memory, and processing speed).
McCarthy Scales of Children’s Abilities [27] (ages 2 years,
6 months to 8 years, 6 months)
 Provides broad picture of abilities.
Children and Adolescents (Early to Mid)
Wechsler’s Intelligence Scale for Children, Forth Edition
Integrated (WISC-IVâ) [28] (ages 6 years to 16 years, 11
months)
 Assesses cognitive abilities (verbal, perceptual, working
memory, and processing speed).
Wechsler Intelligence Scale for Childrenâ-Fourth Edition
Integrated (WISC IVâ) [29].
 Assesses cognitive abilities (verbal, perceptual, working
memory, and processing speed).
 Examiner can determine if underlying processing problems are
affecting WISC-IVâ core test results.
Nonverbal Assessment
Leiter International Performance Scale: Revised [30] (ages 2 years
to 21 years)
Assesses the cognitive abilities of children with low academic
performance (visualization, reasoning, attention, and memory).
378 PRATT & GREYDANUS

These standardized tests yield scores that are called Intelligence Quotients
(IQs). The mean score for most is 100 with a standard deviation of 15. IQ
scores of 70 are two standard deviations below the mean (considering the
standard error of measurement for the specific assessment instrument used
and the instruments strengths and limitations). The obtained scores on the
standardized test must be the result of a valid administration and a true es-
timate of the person’s intellectual abilities; the degrees of ID range from
mild to profound [19]. Assessment of intellectual functioning is only one
component of an assessment for ID.

Severity levels
Degrees of intellectual deficits are determined by deviations from the
mean scores. IQ scores that are two standard deviations from the mean (ob-
tained scores of 50–70) combined with concurrent deficits in adaptive func-
tioning in at least two domains of function and clinical observations and
overall assessment that support such deficits may result in an individual be-
ing labeled with mild mental retardation. Obtained scores of 35 to 55 and the
same additional factors listed above may result in a diagnosis of moderate
mental retardation. Scores between 20 and 40 combined with concurrent
deficits in adaptive functioning and factors as listed above may result in a di-
agnosis of severe mental retardation. Profound mental retardation is based
on those same deficits and scores below 20 to 25. If standardized testing is
unable to be conducted with an individual, but all other deficits are present,
a diagnosis of mental retardation, severity unspecified may be used [19].
ID is an Axis II on the multiaxial coding system used in the American
Academy of Psychiatry’s Diagnostic and Statistical Manual of Mental Dis-
orders or DSM-IV-TR [19]. ID is a pervasive and lifelong condition that is
used as part of the DSM classification systems and identifies individuals who
will need various degrees of social, academic, and work life supports to carry
out tasks of everyday living. The American Association of Mental Retarda-
tion states that there essential factors that must be considered when working
to develop an accurate diagnosis of ID in an individual child or adolescent;
these factors include: (1) cultural issues, (2) environmental conditions (ie,
prematurity, neglect, intellectual deprivation), (3) linguistic issues (eg, com-
prehension and usage or English as a second language), and (4) physical and
motor developmental issues, and the individual’s personal strengths and
weaknesses [17–24].

Differential diagnosis
ID can and often does co-exist with other deficits or disabilities in any do-
main of function (see Appendix 1); ID can also co-occur with other mental
health conditions. The risk of comorbid disabilities is higher for youth with
 INTELLECTUAL DISABILITY IN CHILDREN AND ADOLESCENTS 379

severe mental retardation than for youth with mild mental retardation
[17,19,21,31–33]. Appropriate psychological assessments should clearly dif-
ferentiate between youth who appear to have significant intellectual deficits
and those who are manifesting these symptoms because of psychological
trauma (cognitive and psychomotor functioning) or conditions that have
limited an individual’s ability to learn (ie, neglect or onset of major physical
illness regardless of etiology).

Prognosis
The clinical impact of having sufficient deficits to receive a diagnosis of
ID depends on many factors, including level of severity, access to resources,
and environmental conditions.

Mild mental retardation

Individuals with mild ID may have problems reaching developmental
milestones and acquiring language. With adequate training, most of these
persons will achieve full independence in most domains of function but
may have some problems with adaptive integrative domain [31–33]. As
with many youth, most problems occur when they are matriculating through
the educational system (especially with reading, writing, and timed tests)
and interpersonal relationship skills with peers. Job coaches or aides may
be necessary to help these youth learn work routines and develop solid em-
ployment skills. Most individuals (87%) with ID will exhibit barely notice-
able problems of learning; however, as the demands of academic work
become more complex, differences will become more pronounced. The
more impaired the individual’s functioning, the earlier those differences
will become problematic for the child or adolescent.
Youth who have mild ID often do not experience major psychosocial
problems until they enter the adolescent years, when abstract thinking,
problem solving, critical thinking, and developing the ability to engage in
sustained employment and mutually healthy intimate relationships become
the goals of development. These executive functioning skills become more
essential to one’s successful navigation through social, academic, and emo-
tional situations. Individuals with mild to moderate ID can successfully live
independently as adults and have very normal lives; however, the guidance,
training, and support they receive as children and adults will determine the
level of success a specific individual achieves [15,17,19,20,24].

Moderate mental retardation

In addition to the deficits and needs of the individuals above, those with
moderate mental retardation have more serious deficits in language expres-
sion and comprehension. They will need guidance and support throughout
380 PRATT & GREYDANUS

their lives. Their academic skills will always be limited and may not develop
beyond a basic level. Semi-independent living conditions are usually best
and safest. They will need close supervision in employment endeavors but
can be very dependable and loyal employees if given the appropriate struc-
tured tasks, training, and support. They can develop simple friendships and
engage in appropriately supervised and developed physical activities
[15,17,20,24].

Severe mental retardation

As the degree of functioning decreases, the degree of needed support and
supervision increases. Limitations in expected levels of achievement also
increase. Problems with marked degrees of motor impairment or other asso-
ciated deficits are prevalent. Clinically significant damage to or maldevelop-
ment of the central nervous system is also often a factor [32,33]. These youth
will need care and supervision to perform most activities of daily living
[15,17,19,20,30–33].

Profound mental retardation

Youth who manifest symptoms or behaviors that meet criteria for
profound ID have severe limitations (rudimentary level) in language com-
prehension, expression, and ability to comply with requests or instructions;
they are primarily immobile or severely restricted in mobility, are inconti-
nent, and require constant help and supervision [15,17,19,20,24]. Expecta-
tions for attaining developmental milestones and matriculating through
infancy, childhood, and adolescence to adulthood are severely limited.

Summary
Intellectual disability is a disorder that first develops during pregnancy,
birth, infancy, childhood, or adolescence; diagnosis must occur before age
18. Youth who manifest these symptoms may have significant delays in their
domains of function during development (see Appendix 1). Diagnosis must
be made based on multiple sources of evidence that include attainment of
developmental milestones and cognitive or intellectual disability (two stan-
dard deviations below the mean on standardized intellectual assessments
[Box 2]) and that concurrently occur with (1) deficits (mild to severe) in
adaptive behavior, (2) academic performance, and (3) adaptive functioning.
The majority of youth with ID can live independent or semi-independent
lives as adults if they have received the appropriate personalized support
over a sustained period, especially during the formative years [32,33]. A
list of resources is provided in Box 2.
 INTELLECTUAL DISABILITY IN CHILDREN AND ADOLESCENTS 381

Box 2. Resources
The Arc of the United States
1010 Wayne Avenue, Suite 650
Silver Spring, MD 20,910
301.565.3842
[email protected] (E-mail)
www.thearc.org (Web)
www.TheArcPub.com Web (Publications)
American Association on Intellectual and Developmental
Disabilities (formerly the American Association on Mental
Retardation, AAMR)
444 North Capitol Street NW, Suite 846
Washington, DC 20001-1512
202.387.1968; 800.424.3688 (outside DC)
www.aaidd.org (Web)
Division on Developmental Disabilities
The Council for Exceptional Children
1110 North Glebe Road, Suite 300
Arlington, VA 22,201-5704 888.232.7733; 703.620.3660
866.915.5000 TTY
[email protected] (E-mail)
www.dddcec.org (Web)
The Genetics Home Reference: Your guide to understanding
genetic problems
Genetic Disorders A to Z and related genes and chromosomes
Concepts & Tools for understanding human genetics
http://ghr.nlm.nih.gov/ghr/page/Home

Appendix 1. Domains of function [1–16]

1. Cognitive Domain
 Attention and responses focus generally and selectively
 Ability to sustain focus generally and selectively
 Ability to respond to stimuli
 Ability to respond effectively to environmental cues and stimuli result-
ing in appropriate behavioral adaptation to optimize positive out-
comes and minimize negative outcomes Ability to acquire, store,
retrieve relevant information on demand
 Conceptual learning
B Ability to understand concepts based on familiar information or
situations
382 PRATT & GREYDANUS

B Ability to understand concepts based on combination of old and

new information
B Ability to develop concepts based on new information
 Reasoning inductive, deductive
 Reasoning knowledge of specific facts
 Comprehension of information
 Application of knowledge
 Concrete thinking (here and now, black and white)
 Critical thinking skills
B Compare facts or information
B Contrast facts or information
B Analysis of that knowledge
B Synthesis of that knowledge
B Evaluation of information
B Ability to generate creative strategies from that knowledge
B Abstract thinking
B Insight
B Futuristic thinking
 Problem solving
B Ability to use basic thinking skills to generate a solution to
a problem
B Ability to use basic and critical thinking skills to generate solution
to a problem and make changes in behavior based on that solution
 Basic decision-making skills
n Ability to use basic thinking and problem solving skills to make
a decision
 Complex decision-making skills
n Ability to use basic and critical thinking as well as problem solv-
ing skills to make an appropriate and effective decision
n Ability to change decision based on new information mental flex-
ibility ability to adopt another’s perspective
 Basic planning skills
B Ability to recognize situation in which action is required
B Ability to engage in basic thinking skills
B Ability to engage in basic decision-making skills
B Ability to select a course of action or plan a strategy
 Complex planning skills
B Ability to recognize situation in which action is required
B Ability to analyze the circumstances
B Ability to evaluate a situation
B Ability to use rest of critical thinking skills
B Ability to engage in complex decision-making skills
B Ability to select a course of action
B Ability to plan a strategy
 Basic execution skills
 INTELLECTUAL DISABILITY IN CHILDREN AND ADOLESCENTS 383

B Ability to execute the basic plan

 Complex execution skills
B Ability to execute the complex plan
B Ability to engage in multitasking
B Ability to perform multiple tasks simultaneously
2. Motor domain
 Fine motor
B Pinscher grasp precise
B Specific neuromotor responses
B coordination of fine motor responses
B Drawing objects
B Manipulating object
B Holding objects
 Gross motor
B Head and trunk control
B Purposeful movement of arms and legs
B Crawling, walking
B Running, jumping, skipping, hopping
B Throwing, catching, ability to hit an object (ball) with a bat or
racket
B Total postural control (coordination of skeletal muscles)
 Planning ability
B Ability to balance body during activities
 Muscular strength
 Muscular endurance and agility
 Visual motor tracking
B Extraocular muscle control
B Resting balance control of eye movement
B Visuo-motor coordination
 Perceptual motor
B Integrated stimulus-specific fine motor and gross motor responses
B Visuo-spatial discrimination eye–hand coordination
B Stereognosis judgment of speed
B Judgment of direction
B Judgment of spatial orientation of moving objects
B Awareness of sequential ordering time and sequence of events
 Proprioceptive sense
 Kinesthetic sense time elapsed between stimulus perception and initial
neuromotor responses
3. Auditory
 Hearing acuity
B Processing selective discrimination of sounds
B Selective discrimination of written language
4. Language
 Receptive language: comprehension
384 PRATT & GREYDANUS

B Oral
 Symbolic
 Semantic
 Syntax
B Written
 Symbolic
 Semantic
 Syntax
 Expressive language
B Oral
B Symbolic
B Semantic
B Syntax
 Written
B Symbolic
B Semantic
B Syntax
 Prepositional logic
5. Psychosocial
 Emotional ability to exhibit affect that is appropriate to situation or
set of circumstances
B Ability to monitor emotions
B Ability to regulate emotions
 Social ability to develop friendships
B Ability to sustain friendships
B Ability to develop healthy interpersonal relationships
B Ability to establish mutually beneficial intimate relationships
B Ability to maintain mutually intimate relationships
B Ability to be altruistic
6. Moral judgment
 Discriminate right from wrong
 Sense of morality
7. Specific integrative and adaptive skills
 Ability to coordinate, integrate, and adapt various domains to meet
specific demands of a given task.
 Ability to integrate skills in domains of function to effectively engage
in self-care skills
 Ability to integrate skills in domains and adapt those skills to effec-
tively meet demands of activities of daily living

References
[1] Gesell A, Ilg FL, Ames LB. The child from five to ten. New York: Harper and Row Pub-
lishers; 1946.
 INTELLECTUAL DISABILITY IN CHILDREN AND ADOLESCENTS 385

[2] Gomez JE. Growth and maturation. In: Sullivan AJ, Anderson SJ, editors. Care of the young
athlete. Park Ridge (IL): American Academy of Orthopaedic Surgeons; 2000. p. 25–32.
[3] Blumsack J, Lewandowski L, Waterman B. Neurodevelopmental precursors to learning dis-
abilities: a preliminary report from a parent survey. J Learn Disabil 1997;30(2):228–37.
[4] Branta C, Haubensticker J, Seefeldt V. Age changes in motor skills during childhood and
adolescence. Exerc Sport Sci Rev 1984;12:467–520.
[5] Capute AJ, Accardo PJ. A neurodevelopmental perspective on the continuum of devel-
opmental disabilities. In: Capute AJ, Accardo PJ, editors. Developmental disabilities in
infancy and childhood. 2nd edition. Baltimore (MD): Paul H. Brooks Publishing; 1996.
p. 1–24.
[6] Erickson E. Childhood and society. New York: W.W. Norton and Co., Inc.; 1963.
[7] Erickson E. Identity, youth and crisis. New York: W.W. Norton and Co., Inc.; 1968.
[8] Fagard J. Skill acquisition in children: a historical perspective. In: Bar-Or O. The child and
adolescent athlete. Oxford (UK): Blackwell Science, 1996. p. 74–91.
[9] Gemelli R. Normal child and adolescent development. Washington, DC: American Psychi-
atric Press, 1996.
[10] Levine MD. Neurodevelopmental dysfunction in the school age child. In: Behrman RE,
Kliegman RM, Jenson HB, editors. Nelson textbook of pediatrics. 16th edition. Philadel-
phia: W.B. Saunders Company; 2000. p. 94–100.
[11] Piaget J. Intellectual evaluation from adolescence to adulthood. Hum Dev 1972;15(1):1–12.
[12] Piaget J, Inhelder B. The psychology of the child. New York: Basic Books; 1969.
[13] Rieser JJ, Pick HL, Ashmead DH, et al. Calibration of human locomotion and models of
perceptual-motor organization. J Exp Psychol Hum Percept Perform 1995;21(3):480–97.
[14] Seefeldt V, Haubenstricker J. Patterns, phases, or stages: an analytical model for the study of
developmental movement. In: Kelso JAS, Clark JE, editors. The development of movement
control and coordination. New York: John Wiley and Sons; 1982. p. 309–18.
[15] National. Dissemination Center for Children with Disabilities (NICHCY). Mental Retarda-
tion Fact Sheet 8 (FS8) 2004 Available at: http://www.nichcy.org/pubs/factshe/fs8txt.
htm#whatis. Accessed May 21, 2007.
[16] Luckasson R, Schalock RL, Spitalnik DM, et al. Mental retardation: definition, classifica-
tion, and systems of support. 10th edition. Washington, DC: American Association on
Mental Retardation; 2002. p. 250.
[17] American Association on Mental Retardation (AAMR) (2002). Mental retardation: defini-
tion, classification, and systems of support. 10th edition. Washington, DC: American Asso-
ciation on Mental Retardation (AAMR) Available at: http://www.aamr.org/. Accessed
May 21, 2007.
[18] World Health Organization. Mental retardation division of mental health and prevention
of substance abuse world health organization icd-10 guide for mental retardation. Geneva
(Switzerland): World Health Organization; 1996. p. 1–74. Available at: http://www.who.int/
mental_health/media/en/69.pdf. Accessed May 21, 2007.
[19] American Psychiatric Association: Disorders first diagnosed in infancy, childhood and ado-
lescence. Diagnostic and statistical manual of mental disorders. 4th edition, [text revision]
[DSM-IV-TR]. Washington, DC: American Psychiatric Association, 2000. p. 39–134.
[20] World Health Organization: International classification of diseases and related health prob-
lems (10th edition) [ICD 10]. Geneva (Switzerland): World Health Organization, 1993.
[21] Wolraich MD, Felice ME, Drotar D. The classification of child and adolescent mental diag-
noses in primary care: diagnostic and statistical manual for primary care (DSM-PC) child and
adolescent version. Elk Grove Village (IL): American Academy of Pediatrics; 1996. p. 59–
110.
[22] Department of Health and Human Services, Centers for Disease Control and Prevention.
Developmental disabilities: mental retardation. Atlanta (GA): Department of Health and
Human Services, Centers for Disease Control and Prevention, 2005 Available at: http://
www.cdc.gov/ncbddd/dd/ddmr.htm. Accessed May 21, 2007.
386 PRATT & GREYDANUS

[23] United States Department of Education. Twenty-fourth Annual Report to Congress, to as-
sure the free appropriate public education of all children with disabilities individuals with
disabilities education Act, Section 618. Jessup (MD): United States Department of Education;
2002. Available at: http://www.ed.gov/about/reports/annual/osep/2002/toc-execsum.pdf.
Accessed March 7, 2007.
[24] Department of Health and Human Services, Centers for Disease Control and Prevention.
Developmental disabilities: fetal alcohol spectrum disorders. Atlanta (GA): Department
of Health and Human Services, Centers for Disease Control and Prevention, 2007 Available
at: http://www.cdc.gov/ncbddd/fas/default.htm.
[25] Bayley N. Bayley–IIIÔ screening test. San Antonio (TX): Psychological Corp; 2005. Available
at: http://harcourtassessment.com/hai/Images/pdf/catalog/2007PsychologicalCatalog.pdf.
Accessed May 21, 2007.
[26] Wechsler D. Wechsler’s pre-school and primary scale of intelligence. 4th edition. (WPPSI-
IVÒ). San Antonio (TX): Psychological Corp., Harcourt Brace; 1991. Available at: http://
harcourtassessment.com/hai/Images/pdf/catalog/2007PsychologicalCatalog.pdf. Accessed
May 21, 2007.
[27] McCarthy D: McCarthy scales of children’s abilities. Harcourt assessment; 1972, San Anto-
nio (TX): Psychological Corp., Harcourt Brace. Available at: http://harcourtassessment.
com/hai/Images/pdf/catalog/2007PsychologicalCatalog.pdf. Accessed May 21, 2007.
[28] Wechsler D. Wechsler intelligence scale for children. 4th edition. San Antonio (TX): Psycho-
logical Corp., Harcourt Brace; 1991. Available at: http://harcourtassessment.com/hai/
Images/pdf/catalog/2007PsychologicalCatalog.pdf. Accessed May 21, 2007.
[29] Wechsler D, Kaplan K, Delis D, et al. Wechsler intelligence scale for childrenÒ. 4th edition.
Integrated (WISC d IVÒ). Antonio (TX): Psychological Corp., Harcourt Brace. Available
at: http://harcourtassessment.com/HaiWeb/Cultures/enus/harcourt/Community/Psychology/
results.htm?Community¼CognitionIntelligence. Accessed May 21, 2007.
[30] Roid G, Miller L. Leiter international performance scale: revised. London: nfer-nelson,
Granada Learning Group. Available at: http://shop.nfer-nelson.co.uk/icat/leiterinter
nationalperfor. Accessed May 21, 2007.
[31] Sulkes SB. ‘‘Mental retardation in children and adolescents’’. In: Greydanus DE, Patel DR,
Pratt HD, editors. Behavioral pediatrics. 2nd edition. Lincoln (NE): iUniverse Publishers;
2006. p. 66–82.
[32] Greydanus DE, Bhave S. Adolescents with mental retardation. Recent Advances in Pediat-
rics 2006;17(14):174–92.
[33] Greydanus DE, Pratt HD. Syndromes and disorders associated with mental retardation: se-
lected comments. Indian J Pediatr 2005;72(10):27–32.