The effectiveness of psychosocial and vocational training for mentally challenged in a day care centre

Abstract

Background:

A growing number of mentally challenged individual are being excluded mainly from the educational process because of a presumed inability to learn.

Aim:

The study is aimed at identifying the efficacy of psychosocial and vocational training for mentally challenged in a day care centre.

Methods:

The sample for the study consisted of 30 clinically diagnosed mentally challenged children (N=30, boy=18, girl=12), who are enrolled in Ashadeep day care centre. Methods employed were a semi demographic questionnaire and Vineland Social Maturity Scale to assess the improvement of the child across the various subscales in the pre post test sessions. Correlation coefficient and t-test was used to compare the profile of the children across both the sessions.

Results:

Age of onset of therapy and the duration does not have significant effect on the outcome, but ‘higher the IQ’ more positive outcome can be seen. The subscales do not correlate when it comes to affecting each other. Girls showed much poor outcomes than boys in the self0help general subscale.

Conclusions:

The study ascertained the fact that education and training of the mentally subnormal child is also possible, and psychosocial and vocational training lead to improving the social competence of the child.

Introduction

The mentally retarded children differ only in degree, but not in kind, from the normal child. The objective of the education and training of the mentally subnormal child was to give him social competence. Mental retardation (MR) is a highly prevalent and disabling condition. Depending on the severity of their disability, mentally retarded are more and more dependent on their caregivers.

The Census of India (2001) and the National Sample Survey Organization (NSSO 2002) estimated that four per cent of the population suffers from MR with the prevalence being more high among rural population then in urban population.^[1] According to the American Association of Mental Deficiency (later the American Association of Mental Retardation, and now The American Association on Intellectual and Developmental Disabilities),^[2] “Mental Retardation can be defined as significantly sub average general intellectual functioning, resulting in or associated with concurrent impairment in adaptive behaviour, and is manifested during the developmental period”.

Two main primary concerns related to mentally retarded children are the recognition that this group uses a disproportionate amount of specialised services although these services prove to be beneficial to a greater extent. Secondly, these sections of the population are excluded from the educational process because of their presumed inability to learn. But the fact is that with quality education, support, increased environmental stimulations and early intervention, individuals with disabilities learn both academic and nonacademic skills. Research showed that admission of the mentally retarded children into the specialised psychosocial rehabilitation programmes aims to enhance the skills of daily living, socialisation, vocational training, meaningful employment, and increase independent living.^[3]

According to the United States Psychiatric Rehabilitation Association,^[4] “Psychosocial rehabilitation services are collaborative, person-directed, and individualised, an essential element of the human services spectrum, and should be evidence-based. They focus on helping individuals develop skills and access resources needed to increase their capacity to be successful and satisfied in the living, working, learning and social environments of their choice”.

Many outcome researches have documented a positive impact of psychosocial rehabilitation efforts on improvement in the level of functioning of persons with MR in teaching mathematics following interventions stressing frequent feedback, explicit instruction, and ample drill and practice.^[5] Training programmes have an impact on improving skills in a variety of areas, including personal hygiene, activities of daily living, physical fitness, interpersonal skills, self-control skills, and socialisation skills.

Thus, in the present study an attempt has been made to bridge the gap between the unavailability of psychosocial training, and the efficacy of psychosocial and vocational training to the mentally retarded to build independent working members in the society.

Review of literature

Individuals with subnormal intellectual level and multiple disabilities of all ages are presumed to have inability to learn and acquire skills especially with regard to academic skills, so the growing need of special schools for increasing the social competence of the children is felt for doing the study which is supported by a number of studies.

Reviews can be classified under the following categories:

1. Learning ability of mentally retarded, and

2. Positive outcomes of family environment.

1. Learning ability of mentally retarded:

While past perceptions questioned the ability of those with severe disabilities to learn,^[6,7] current perspectives support the notion that all individuals can and do learn.^[8–10] How they learn may vary somewhat from others who do not have disabilities, but the acquisition of skills in a variety of venues is well-documented.

Students with severe disabilities have learned to eat independently, do their laundry, and dress themselves;^[11–13] they have increased their communication skills,^[14,15] improved their social skills,^[16,17] and safety skills.^[18] Mentally retarded children also showed learning laundry task with the use of response prompting.^[13] Mild to moderate mentally retarded are able to learn both specific target skills (e.g., matching shapes, counting money, graphing, and computation) and functional life skills involving mathematics.^[19] Importance of early intervention programmes in preschools for children with disability have shown positive outcomes.^[20] For teaching academics to students with severe developmental disability systematic prompting, feedback and time delay were used most often while stimulus fading and teaching formats were used most often in one to one instruction.^[21]

2. Positive outcomes of family environment:

The importance of family unit, along with supportive intervention, effectiveness of psycho-educational approach for the staff families and interventions in areas such as housing, leisure, and employment are well-described in research works. Findings also suggest that persons with mild and moderate MR from special schools showed similar level of generic skills, work traits and work aptitude, and acquiring vocational skills.^[22] Also study on parents showed that having intellectually deficient child is not viewed as a sign of so-called “ bad fortune or misfortune” to everyone, but it can be a challenge which strengthens the parents of those patients and teaches them to be more positive towards their outlook.^[23]

As it can be clearly seen from the reviews that, mentally retarded individuals learn both academic and nonacademic skills when they are expected to learn and given quality instruction, feedback, and support.

Methodology

A cross sectional study was adopted to assess the efficacy of psychosocial and vocational training in a day care centre for mentally retarded children. Sample included 30 children fulfilling the tenth edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-10)^[24] classification of mental retardation, who were enrolled in Ashadeep day care centre, situated in Guwahati, Assam, India.

About the day care centre: The focus of Ashadeep day care centre is to provide psychosocial rehabilitation to individuals who are impaired or disabled by a mental disorder/disability for intervention and reduction of caregiver’s burden. Activities involve providing training in self-help skills, social skills, vocational skills training by special educators and trained therapists. Under vocational skills students are taught to produce things such as door mate, making diyas, decorating diyas and pots, file making, block printing, spray printing, fabric, hand stitch.

Tools employed are: a) Specially designed socio-demographic data sheet, b) Vineland Social Maturity Scale (VSMS) (Nagpur adaptation).

• a)Specially designed socio-demographic data sheet

  A format was developed to record the like name, age, sex, level of retardation, family size, family income, socioeconomic status, other contact details and so on.

• b)Vineland Social Maturity Scale (Nagpur adaptation)

The scale was originally developed by E. A. Doll in 1935,^[25] which was then adapted by Dr. A.J. Malin in the year 1965.^[26] It measures differential social capacity of an individual. It provides an estimate of social age (SA) and social quotient (SQ) and shows high correlation (0.80) with intelligence. It is designed to measure social maturation in eight social areas viz. self-help general (SHG), self-help eating (SHE), self-help dressing (SHD), self-direction (SD), locomotion (LOC), occupation (OCC), communication (COM), and socialisation (SOC). The scale consists of 89 items grouped into year levels (13 age groups). It can be used for the age group of ‘below 15 years’; it means from birth to 15 years.

Procedure:

The sample was randomly selected and VSMS was given in two sessions: 1) In the first assessment, i.e. pre test, assessment is done based on data collected from the previous year’s records at the time of admission of the child to Ashadeep day care centre; 2) In the second assessment, i.e. post test, assessment is done to the children directly on 2013.

Data collection:

Thirty research participants were selected randomly and consented for the study. Eighteen of them are boy and 12 are girl. Face to face individual interaction was then initiated to gather information about these children from their parents, special educator; monthly assessment records acquired from the centre and the children itself about their level of functioning. Ethical clearance was obtained for the research project.

Participants were selected according to the inclusive criteria taken for the study, which are:

• a)Children with intelligence quotient (IQ) below 70, who are clinically diagnosed as mentally retarded.
• b)Children admitted to the day care centre within the age group of five to 30 years.
• c)Children who have been continuing their enrolment in Ashadeep day care centre, and seeking the psychosocial and vocational training for two years or more.

Further, the development in the eight areas of functioning was assessed by VSMS which was compared to find the difference across pre training and post training.

The VSMS scale was used to assess IQ and to compute the profile across the subscales, plan for the intervention accordingly and assess the progressive changes in the skills acquirement and performance in various domains with training.

Results and Discussion

With the aim of assessing the effectiveness of psychosocial and vocational training both parametric and non parametric statistics were used.

The socio-demographic profile reveals that the average age for the sample was 12 years, seven months, i.e.153.4 months. The average duration of the therapy provided to the children was found to be five years, seven months, i.e. 68.5 months. The average IQ of the sample was found to be 48.49, i.e. according to VSMS, the average IQ of the sample was found to be within the moderate mental retardation level (Table 1).

Table 1:

The average age, duration of therapy, and IQ level of the mentally retarded children

	Study population
Numbers	30
Age (mean) in months	153.4
Duration of therapy (mean) in months	68.5
IQ (mean)	48.49

IQ=intelligence quotient

There is no significant difference in the baseline scale variable across the various subscales according to sex, i.e. boy:girl ratio; since p-value > 0.05, indicating that the change can be attributed to random fluctuations (Table 2).

Table: 2.

Difference in baseline scale variable according to sex

	Boy	Girl	Group (mean)	u-statistic	p-value
SHG	56.28±21.3	57.50±24.9	58.47	82.5	0.2491
SHE	61.76±17.3	67.42±35.6	76.77	98.0	0.6819
SHD	73.89±43.0	59.72±35.5	75.73	86.0	0.3443
SD	81.09±35.2	67.91±39.3	91.73	101.5	0.7160
OCC	67.11±47.7	74.06±35.1	61.47	91.5	0.4934
COM	88.67±50.1	80.92±34.0	63.00	95.0	0.5899
LOC	93.11±26.0	58.67±23.6	76.80	91.5	0.4860
SOC	89.67±23.4	63.58±23.7	60.63	85.5	0.3283

SHG=self-help general, SHE=self-help eating, SHD=self-help dressing, SD=self-direction, OCC=occupation, COM=communication, LOC=locomotion, SOC=socialisation

There is significant difference in the pre post test values of VSMS subscales, since p < 0.01 indicating that with training, i.e. pre test, there can be seen improvement in outcome, i.e. post test (Table 3). Research have supported that with training, task performance can be improved which focused on visual rather than verbal cuing because it was used with nonverbal children.^[27] It has been proved that MR in childhood can have negative consequences for the development of language, literacy, social skills, personal relationships, and a sense of personal history,^[28] also impeding academic performance, particularly arithmetic.^[29] However, interventions during development have the potential to improve memory performance, and can have positive impacts on related cognitive skills.

Table 3:

Comparison of pre and post test values of VSMS sub-scales

	Pre-test	Post-test	t-test p-value
SHG	58.47 ± 19.64	70.17 ± 23.80	0.000756
SHE	76.77 ± 39.62	99.37 ± 35.10	0.000119
SHD	75.73 ± 49.00	113.33 ± 66.07	0.000005
SD	91.73 ± 24.63	115.60 ± 46.37	0.008243
OCC	61.47 ± 29.50	92.70 ± 49.49	0.000145
COM	63.00 ± 36.63	80.60 ± 46.47	0.000649
LOC	76.80 ± 34.27	99.70 ± 32.41	0.000174
SOC	60.63 ± 23.36	82.43 ± 33.18	0.000771

VSMS=Vineland Social Maturity Scale, SHG=self-help general, SHE=self-help eating, SHD=self-help dressing, SD=self-direction, OCC=occupation, COM=communication, LOC=locomotion, SOC=socialisation

When IQ, age of onset of therapy, and duration of therapy were considered for the study, significant differences can be found with IQ in some of the VSMS subscales, i.e. SD, OCC, COM, and SOC, but no significant difference was found with age of onset of therapy and duration of therapy (Table 4). In other words, it can be explained as, with the age of onset of therapy and the duration, no significant effect on the outcome can be found, but with ‘higher IQ’ effects the outcome turns out to be more positive.

Table 4:

Change in the scale variable of the mentally retarded children

	IQ		Age of onset of therapy		Duration of therapy
	R	p-value	R	p-value	R	p-value
SHG	0.24	0.2032	0.19	0.3043	0.34	0.0639
SHE	0.12	0.5302	−0.23	0.2179	0.23	0.2259
SHD	0.36	0.0508	0.14	0.4670	0.23	0.2216
SD	0.49	0.0052*	0.08	0.6684	0.09	0.6442
OCC	0.39	0.0329*	0.08	0.6809	0.13	0.5040
COM	0.41	0.0229*	0.10	0.6096	0.32	0.0836
LOC	−0.00	0.9972	−0.05	0.7864	0.20	0.2778
SOC	0.38	0.0369*	0.37	0.0446*	−0.25	0.1853

^*significant

IQ=intelligence quotient, SHG=self-help general, SHE=self-help eating, SHD=self-help dressing, SD=self-direction, OCC=occupation, COM=communication, LOC=locomotion, SOC=socialisation

Memory, learning, self-determination are some of the factors that can be attributed to positive results among mentally retarded. Research has found that students with MR have trouble retaining information in short-term memory.^[30] Merrill^[31] reports that students with MR require more time than their nondisabled peers to automatically recall information, and therefore have more difficulty handling larger amounts of cognitive information at one time. Early researchers suggested that once persons with MR learned a specific item of information sufficiently to commit it to long-term memory, they are able to retain that information without any difficulty.^[32,33] Students with MR do not tend to use strategies such as rehearsing, organising information into related sets spontaneously, but they can be taught to do so with improved performance on memory-related and problem-solving tasks, as an outcome of such strategy instruction.^[31,34]

Importance of learning capacity of the mentally retarded has also been acknowledged. Research has shown that students with MR benefit from opportunities to learn to “go fast”.^[35] Research states that learning is an individualised student-centred approach that may be one very meaningful part of a student’s overall programme irrespective of the child’s condition which supports the student’s acquisition of academic, vocational, recreational, and domestic skills in meaningful and natural environments. The instructional approach to learning supports life-long learning across all venues of living. One of the major factors associated with higher expectations for learning is the relatively recent emphasis on teaching self-determination skills.^[36,37] Instead of viewing students with severe disabilities as recipients of the decisions made by others, teaching these individuals the skills they need to make decisions for themselves is a growing trend. Self-determination skills can include simple choice-making, as well as more advanced skills, such as decision-making, problem-solving, goal setting, self-monitoring, and self-evaluation. When students can learn to advocate for themselves, the dependence on others is reduced. Many children and adults with MR display tenacity and curiosity in learning, get along well with others, and are positive influences on those around them.^[38,39]

The “self-fulfilling prophecy” (SFP) may be considered as another factor leading to positive consequence among the mentally retarded children. SFP, also referred to as “Pygmalion Effect”, has long been studied by sociologists and psychologists under various labels.^[40–43] Cotton^[44] reported the original Pygmalion study that the Rosenthal/Jacobson study concluded that students’ intellectual development is largely a response to what teachers expect and how those expectations are communicated. These results led the researchers to claim that the inflated expectations teachers held for the target students (and, presumably, the teacher behaviours that accompanied those high expectations) actually caused the students to experience accelerated intellectual growth.

In the field of special education, expressed emotion (EE) was first investigated (in the 1970s and 1980s) with regard to the potential negative consequences of being labelled “mentally retarded”.^[45] In general, this “stigma” research suggested that being labelled mentally retarded often led to changes in the behaviour of adults who encouraged “learned helplessness”.^[46] These studies reported that the attribution for success or failure for a mentally retarded person was more frequently assigned to the person’s inherent low ability, while failure attribution for others was more frequently assigned to the person’s effort.

There is a positive correlation when comparing IQ and the VSMS (Figure 1).

Figure 1:

The correlation between IQ and few of the subscales.

IQ=intelligence quotient, SD=self-direction, OCC=occupation, COM=communication, SOC=socialisation

Girls showed much poor outcomes than boys in the SHG subscale. This might be attributed to low motivation as a result to poor family involvement, or late onset of therapy. Research also suggests that some students with MR exhibit an apparent lack of interest or low motivation in learning or problem-solving tasks.^[47] Some individuals with MR develop learned helplessness, a condition in which a person who has experienced repeated failure comes to expect failure regardless of his or her efforts. In an attempt to minimise or offset failure, the person may set extremely low expectations for himself and not appear to try very hard. Rather than an inherent characteristic of MR, the apparent lack of motivation may be the product of frequent failure and prompt dependency acquired as the result of other people’s doing things for them.

Future Directions and Limitations

This is the first study done in Assam to study the effects of intervention in a day care centre by trained professionals in adaptive functioning and independent living skills training for MR. The findings of the study created importance to such studies to formulate a guiding pattern for day care centres. The study would help in creating awareness that mentally retarded children are also capable of learning through a structured training. Insight facilitation about the benefit of structured training programme for mentally challenged individuals.

Although the study has many implications for future benefits but it could not be kept away from its limitations which are as follows:

• a)No control group was chosen for the study.
• b)The level of MR was not studied separately, i.e. as mild, moderate, severe, and profound.
• c)Family’s contribution to training the child at home was not assessed.
• d)An economic factor was not taken into consideration.
• e)Parental factors, i.e. parental involvement and outlook of the parents towards the child also play a crucial role in the child’s development which was not considered for the study.
• f)Natural improvement with time which might be a factor leading to child’s development was not considered for the study.
• g)Children with severe and profound MR may not be showing immediate positive feedback in acquiring of the skills over a period of providing training which may lead to special educator’s bias in training them.

Conclusion and Summary

The main finding of the study suggests that:

• a)Age of onset of therapy and the duration does not have significant effect on the outcome, but ‘higher the IQ’ more positive outcome can be seen.
• b)The subscales do not correlate when it comes to affecting each other.
• c)Girls showed much poor outcomes than boys in the SHG subscale.

The study ascertained the fact that education and training of the mentally subnormal child is also possible, and psychosocial and vocational training lead to improving the social competence of the child. It must be recognised that MR of all ages typically need more time, more opportunities, and most importantly, special methods of education and training to acquire and practice skills. The greatest importance for the subnormal children lies in the pre-school years for laying a foundation of perceptual and cognitive abilities, of language, and of emotional and social responsiveness.

Therefore, the importance of specialised classroom involving psychosocial rehabilitation for the mentally retarded children to eliminate the practice of excluding these children with special needs have been highlighted in the study.