Intellectual Disability earlier known as Mental Retardation

Clinical Characteristics of Intellectual Disabilities

DIAGNOSIS AND ASSESSMENT

Intelligence is the general mental capacity that involves reasoning, planning, solving problems,
thinking abstractly, comprehending complex ideas, learning efficiently, and learning from
experience (American Association on Intellectual and Developmental Disabilities, AAIDD,
2010). Historically, intellectual disability (previously termed “mental retardation”) has been
defined by significant cognitive deficits—which has been established through a standardized
measure of intelligence, in particular, with an IQ score of below 70 (two standard deviations
below the mean of 100 in the population)—and also by significant deficits in functional and
adaptive skills. Adaptive skills involve the ability to carry out age-appropriate daily life
activities. Two different systems for classifying intellectual disability (ID) used in the United
States are that of the American Association on Intellectual and Developmental Disabilities
(AAIDD) and the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5),
which is published by the American Psychiatric Association. Both of these systems classify
severity of ID according to the levels of support needed to achieve an individual's optimal
personal functioning (Table 1).
 Table 1. Classifications of Intellectual Disability Severity

AAIDD Supplemental Security

DSM-IV Criteria Income (SSI) Listings
Criteria (severity Criteria (The SSI listings
Approximate (severity classified on do not specify severity
Percent levels were DSM-5 Criteria the basis of levels, but indicate
Distribution based only (severity classified intensity of different standards for
Severity of Cases by on IQ on the basis of daily support meeting or equaling listing
Category Severity categories) skills) needed) level severity.)

Mild 85% Approximate Can live Intermittent IQ of 60 through 70 and a

IQ range 50– independently with support physical or other mental
69 minimum levels of needed during impairment imposing an
support. transitions or additional and significant
periods of limitation of function
uncertainty.

Moderate 10% Approximate Independent living Limited A valid verbal,

IQ range 36– may be achieved support performance, or full-scale
49 with moderate levels needed in IQ of 59 or less
of support, such as daily
those available in situations.
group homes.

Severe 3.5% Approximate Requires daily Extensive A valid verbal,

IQ range 20– assistance with self- support performance, or full-scale
35 care activities and needed for IQ of 59 or less
safety supervision. daily
activities.
 AAIDD Supplemental Security
DSM-IV Criteria Income (SSI) Listings
Criteria (severity Criteria (The SSI listings
Approximate (severity classified on do not specify severity
Percent levels were DSM-5 Criteria the basis of levels, but indicate
Distribution based only (severity classified intensity of different standards for
Severity of Cases by on IQ on the basis of daily support meeting or equaling listing
Category Severity categories) skills) needed) level severity.)

Profound 1.5% IQ <20 Requires 24-hour Pervasive A valid verbal,

care. support performance, or full-scale
needed for IQ of 59 or less
every aspect
of daily
routines.

DSM-5 defines intellectual disabilities as neurodevelopmental disorders that begin in childhood

and are characterized by intellectual difficulties as well as difficulties in conceptual, social, and
practical areas of living. The DSM-5 diagnosis of ID requires the satisfaction of three criteria:

1. Deficits in intellectual functioning—“reasoning, problem solving, planning, abstract

thinking, judgment, academic learning, and learning from experience”—confirmed by
clinical evaluation and individualized standard IQ testing (APA, 2013, p. 33);
2. Deficits in adaptive functioning that significantly hamper conforming to developmental
and sociocultural standards for the individual's independence and ability to meet their
social responsibility; and
3. The onset of these deficits during childhood.

The DSM-5 definition of ID encourages a more comprehensive view of the individual than was
true under the fourth edition, DSM-IV. The DSM-IV definition included impairments of general
mental abilities that affect how a person functions in conceptual, social, and daily life areas.
DSM-5 abandoned specific IQ scores as a diagnostic criterion, although it retained the general
notion of functioning two or more standard deviations below the general population. DSM-5 has
placed more emphasis on adaptive functioning and the performance of usual life skills. In
contrast to DSM-IV, which stipulated impairments in two or more skill areas, the DSM-5 criteria
point to impairment in one or more superordinate skill domains (e.g., conceptual, social,
practical) (Papazoglou et al., 2014).

Details of the diagnostic criteria for ID in DSM-5 are as follows:

1. Deficits in intellectual functioning
This includes various mental abilities:
• Reasoning;
• Problem solving;
• Planning;
• Abstract thinking;
• Judgment;
• Academic learning (ability to learn in school via traditional teaching methods);
• Experiential learning (the ability to learn through experience, trial and error, and
observation).
These mental abilities are measured by IQ tests. A score of approximately two standard
deviations below average represents a significant cognitive deficit. These scores would occur
about 2.5% of the population. Or stated differently, 97.5% of people of the same age and culture
would score higher. The tests used to measure IQ must be standardized and culturally
appropriate. This is typically an IQ score of 70 or below.

2. Deficits or impairments in adaptive functioning

This includes skills needed to live in an independent and responsible manner. Limited abilities in
these life skills make it difficult to achieve age appropriate standards of behavior. Without these
skills, a person needs additional supports to succeed at school, work, or independent life. Deficits
in adaptive functioning are measured using standardized, culturally appropriate tests.
Various skills are needed for daily living:
• Communication: This refers to the ability to convey information from one person to
another. Communication is conveyed through words and actions. It involves the ability to
understand others, and to express one's self through words or actions.
• Social skills: This refers to the ability to interact effectively with others. We usually take
social skills for granted. However, these skills are critical for success in life. These skills
include the ability to understand and comply with social rules, customs, and standards
 •

• of public behavior. This intricate function requires the ability to process figurative
language and detect unspoken cues such as body language.
• Personal independence at home or in community settings: This refers to the ability to
take care of yourself. Some examples are bathing, dressing, and feeding. It also includes
the ability to safely complete day-to-day tasks without guidance. Some examples are
cooking, cleaning, and laundry. There are also routine activities performed in the
community. This includes shopping for groceries and accessing public transportation.
• School or work functioning: This refers to the ability to conform to the social standards
at work or school. It includes the ability to learn new knowledge, skills, and abilities.
Furthermore, people must apply this information in a practical, adaptive manner; without
excessive direction or guidance.
3. These limitations occur during the developmental period. This means problems with
intellectual or adaptive functioning were evident during childhood or adolescence. If these
problems began after this developmental period, the correct diagnosis would be neurocognitive
disorder. For instance, a traumatic brain injury from a car accident could cause similar
symptoms.

Classifications of Severity

The terms “mild,” “moderate,” “severe,” and “profound” have been used to describe the severity
of the condition (Table 1). This approach has been helpful in that aspects of mild to moderate ID
differ from severe to profound ID. The DSM-5 retains this grouping with more focus on daily
skills than on specific IQ range.

Mild to Moderate Intellectual Disability

The majority of people with ID are classified as having mild intellectual disabilities. Individuals
with mild ID are slower in all areas of conceptual development and social and daily living skills.
These individuals can learn practical life skills, which allows them to function in ordinary life
with minimal levels of support. Individuals with moderate ID can take care of themselves, travel
to familiar places in their community, and learn basic skills related to safety and health. Their
self-care requires moderate support.

Severe Intellectual Disability

Severe ID manifests as major delays in development, and individuals often have the ability to
understand speech but otherwise have limited communication skills (Sattler, 2002). Despite
being able to learn simple daily routines and to engage in simple self-care, individuals with
severe ID need supervision in social settings and often need family care to live in a supervised
setting such as a group home.

Profound Intellectual Disability

Persons with profound intellectual disability often have congenital syndromes (Sattler, 2002).
These individuals cannot live independently, and they require close supervision and help with
self-care activities. They have very limited ability to communicate and often have physical
limitations. Individuals with mild to moderate disability are less likely to have associated
medical conditions than those with severe or profound ID.

Evaluation of Severity

Currently AAIDD publishes a framework for evaluating the severity of ID, the Supports
Intensity Scale (SIS), which focuses on the types and intensities of supports needed to enable an
individual to lead a normal and independent life, rather than defining severity in terms of
deficits. The SIS evaluates the support needs of an individual across 49 life activities, divided
into six categories: home living, community living, life-long learning, employment, health and
safety, and social activities.

DSM-5 notes that intellectual functioning reflects several different components: verbal
comprehension, working memory, perceptual reasoning, quantitative reasoning, abstract thought,
and cognitive efficacy (APA, 2013). Accurate measurement requires an instrument that is
psychometrically valid, culturally appropriate, and individually administered. In the absence of
appropriate measurement instruments, screening instruments are still able to assist in the
identification individuals who need further testing. IQ test results fall along the normal (bell-
shaped) curve, with an average IQ of 100, and individuals who are intellectually disabled are
usually two standard deviations below the average (IQ below 70). Various issues (e.g., co-
occurring communication problems, sensory or motor difficulties) can affect assessment, and
psychologists must address these in considering which tests to use. IQ scores are usually reported
with an associated confidence interval which indicates a range within which the “true” score is
likely to fall.

A frequently used IQ measure for children in the United States is the Wechsler Intelligence Scale
for Children (WISC-V). It historically measured verbal IQ, performance IQ, and full
performance IQ (Wechsler et al., 2004). In its most recent edition, the WISC-V provides an
overall IQ score as well as five other scores for verbal comprehension, visual spatial skills, fluid
reasoning, working memory, and processing speed (Pearson Education, 2015). Because IQ
scores have been constantly rising since the 1930s, standardized IQ tests have been periodically
renormed based on the current population (Flynn, 1987).

FUNCTIONAL IMPAIRMENT

The diagnosis of ID requires evidence of impairments in real life (adaptive) skills; thus, all
people with ID demonstrate functional impairment. These adaptive abilities relate to such things
as understanding rules, the ability to navigate the tasks of daily living, and participation in
family, school, and community activities. Various assessments of such skills are available, such
as the Vineland Adaptive Behavior Scales which is a widely used instrument (Sparrow et al.,
2005). Assessment of these skills helps to plan remediation, i.e., teaching specific skills and
working on generalization of skills.

DEMOGRAPHIC FACTORS AND DURATION OF THE DISORDER

ID begins in the first two decades of life. The age and characteristics of onset depend on the
cause of the disability and the severity of the neuropsychiatric dysfunction. The identification of
children with more severe ID (what previously would have been termed severe and profound
mental retardation) typically occurs early in life. These children often have dysmorphic features
and associated medical conditions and higher rates of behavioral and psychiatric disturbances.
Individuals with severe intellectual disability may show delayed motor, language, and social
accomplishments within the first 2 years of life. Individuals with mild intellectual disability may
not be recognized until early school age because that is when their difficulties with academic
learning become apparent.

Depending on its cause, ID may be stable and nonprogressive or it may worsen with time. After
early childhood, the disorder is chronic and usually lasts an individual's lifetime; however, the
severity of the disorder may change with age. For example, visual or hearing difficulties,
epilepsy, childhood psychological or head trauma, substance abuse, and other medical conditions
may affect the course of the disorder. Conversely, an early intervention may improve adaptive
skills.

Prevalence and Gender Ratio

Males are more likely than females to be diagnosed with ID. According to the National Health
Interview Survey, from 1997 to 2008 the prevalence of ID was 0.78 percent in boys and 0.63
percent in girls (Boyle et al., 2011). Overall, studies of prevalence show a male excess in the
prevalence of ID, which is partially explained by x-linked causes of the disability, such as fragile
X syndrome (Durkin et al., 2007).

Race/Ethnicity

In the United States, the prevalence of ID varies by race/ethnicity, probably due to confounding
by socioeconomic status (SES). Black non-Hispanic children are approximately twice as likely,
and Hispanic children approximately one and a half times as likely, to be diagnosed with ID as
white non-Hispanic children (Bhasin et al., 2006; Boyle and Lary, 1996; Boyle et al.,
2011; Camp et al., 1998; Van Naarden Braun et al., 2015). Language differences and poverty are
likely to contribute to the racial and ethnic differences in performance on cognitive tests and to
the corresponding disparities in prevalence. Even after taking the effects of SES into account,
there is evidence that test bias and diagnostic bias affects the rates of the diagnosis of ID (Jencks
and Phillips, 1998).
Socioeconomic Status

Poverty is one of the most consistent risk factors for ID (Cooper and Lackus, 1983; Durkin et al.,
1998; Stein and Susser, 1963). Boyle and colleagues reported that in the United States between
1997 and 2008, the prevalence of ID among children below 200 percent of the federal poverty
level (FPL) was 1.03 percent, while for those above 200 percent FPL the rate was 0.5 percent
(Boyle et al., 2011). Similarly, Camp and colleagues found the prevalence of ID among children
of low SES to be more than twice as high as that among middle- or high-SES children (Camp et
al., 1998). The association between low SES and poverty is considerably stronger for mild than
for more severe levels of ID (Drews et al., 1995; Durkin et al., 1998).

COMORBIDITIES

Many neurodevelopmental, psychiatric, and medical disorders co-occur with ID, especially
communication disorders, learning disabilities, cerebral palsy, epilepsy, and various genetically
transmitted conditions (APA, 2013). Estimates of the rates of psychiatric coexisting conditions
vary. For many years there was an underestimation of the increased risk for development of
comorbid conditions (“diagnostic overshadowing”). As research was conducted, it became clear
that the risk for comorbid conditions is greater than previously believed. For example, Rutter and
colleagues (1970) reported rates of 30 to 42 percent of psychopathology in children with “mental
retardation” compared with 6 to 7 percent in children without the disability. Gillberg and
colleagues (1986) reported that 57 percent of subjects with mild and severe “mental retardation”
met diagnostic criteria for affective, anxiety, conduct, schizophrenia, and somatoform disorders
and attention deficit hyperactivity disorder (ADHD). Most studies indicate a four- to fivefold
increase in mental health problems among individuals with ID. In general, at least 25 percent of
persons with ID may have significant psychiatric problems, with the population experiencing, in
particular, significantly increased rates of schizophrenia, depression, and ADHD (Bouras and
Holt, 2007; Fletcher et al., 2007).
Etiology

Genetic Chromosomal Factors

Intellectual disability, especially mild disability, tends to run in families. Poverty and
sociocultural deprivation, however, also tend to run in families. Early and continued exposure to
such conditions, even the inheritance of average intellectual potential, may not prevent below-
average intellectual functioning.

Genetic-chromosomal factors play a much clearer role in the etiology of relatively infrequent but
more severe types of intellectual disability such as Down syndrome and a heritable condition
known as fragile X (Huber & Tamminga, 2007; Schwarte, 2008). The gene responsible for
fragile X syndrome (FMR-1) was identified in 1991 (Verkerk et al., 1991). In such conditions,
genetic aberrations are responsible for metabolic alterations that adversely affect the brain’s
development. Genetic defects leading to metabolic alterations may also involve many other
developmental anomalies besides intellectual disability (e.g., autism) (Wassink et al., 2001).
Intellectual disability associated with known genetic-chromosomal defects tends to be moderate
to severe in nature.

Infections and Toxic Agents

Intellectual disability also can result from a wide range of conditions due to infection, such as
viral encephalitis or genital herpes (Kaski, 2000). If a pregnant woman is infected with syphilis
or HIV-1 or if she gets German measles, her child may suffer brain damage as a result.

A number of toxic agents such as carbon monoxide and lead may cause brain damage during
fetal development or after birth (Kaski, 2000). Similarly, if taken by a pregnant woman, certain
drugs, including an excess of alcohol (West et al., 1998), may lead to congenital malformations.

And an overdose of drugs administered to an infant may result in toxicity and cause brain
damage. In rare cases, brain damage results from incompatibility in blood types between mother
and fetus. Fortunately, early diagnosis and blood transfusions can minimize the effects of such
incompatibility.
Trauma and Physical Injury

Physical injury at birth can result in intellectual disability (Kaski, 2000). Although the fetus is
normally well protected by its fluid-filled placenta during gestation, and although its skull resists
delivery stressors, accidents that affect development can occur during delivery and after birth.
Difficulties in labor due to malposition of the fetus or other complications may irreparably
damage the infant’s brain. Bleeding within the brain is probably the most common result of such
birth trauma. Hypoxia—lack of sufficient oxygen to the brain stemming from delayed breathing
or other causes—is another type of birth trauma that may damage the brain.

Ionizing Radiation

In recent decades, a good deal of scientific attention has focused on the damaging effects of
ionizing radiation on sex cells and other bodily cells and tissues. Radiation may act directly on
the fertilized ovum or may produce gene mutations in the sex cells of either or both parents,
which may lead to intellectual disability among offspring. Sources of harmful radiation were
once limited primarily to high-energy X-rays used in medicine for diagnosis and therapy, but the
list has grown to include nuclear weapons testing and leakages at nuclear power plants, among
others.

Malnutrition and Biological Factors

It was long thought that dietary deficiencies in protein and other essential nutrients during early
development of the fetus could do irreversible physical and mental damage. However, it is
currently believed that this assumption of a direct causal link may have been oversimplified.
Ricciuti (1993) cited growing evidence that malnutrition may affect mental development more
indirectly by altering a child’s responsiveness, curiosity, and motivation to learn, which would in
turn lead to intellectual disability. The implication here is that at least some malnutrition-
associated intellectual deficit is a special case of psychosocial deprivation, which is also involved
in disability-related outcomes.
Organic Intellectual Disability Syndromes

Intellectual disability stemming primarily from biological causes can be classified into several
recognizable clinical types (Murphy et al., 1998), examples of which are Down syndrome,
phenylketonuria, and cranial anomalies:

Down Syndrome

First described by Langdon Down in 1866, Down syndrome is the best known of the clinical
conditions associated with moderate and severe intellectual disability. The prevalence of Down
syndrome has been reported to be 5.9 per 10,000 of the general population (Cooper et al., 2009).
It is a condition that creates irreversible limitations on intellectual achievement, competence in
managing life tasks, and survivability (Patterson & Lott, 2008). It also is associated with health
problems in later life such as pneumonia and other respiratory infections. The availability of
amniocentesis and chorionic villus sampling in expectant mothers has made it possible to detect
in utero the extra genetic material involved in Down syndrome, which is most often the trisomy
of chromosome 21, yielding 47 rather than the normal 46 chromosomes.

The Clinical Picture in Down Syndrome

A number of physical features are often found among children with Down syndrome, but few of
these children have all of the characteristics commonly thought to typify this group. The eyes
appear almond shaped, and the skin of the eyelids tends to be abnormally thick. The face and
nose are often flat and broad, as is the back of the head. The tongue, which seems too large for
the mouth, may show deep fissures. The iris of the eye is frequently speckled. The neck is often
short and broad, as are the hands. The fingers are stubby, and the little finger is often more
noticeably curved than the other fingers. Although facial surgery is sometimes tried to correct the
more stigmatizing features, its success is often limited (Roizen, 2007). Parents’ acceptance of
their Down syndrome child is inversely related to their support of such surgery (Katz et al.,
1997).

Death rates for children with Down syndrome have decreased dramatically in the past century. In
1919 the life expectancy at birth for such children was about 9 years; most of the deaths were
due to gross physical problems, and a large proportion occurred in the first year of life. Thanks to
antibiotics, surgical correction of lethal anatomical defects such as holes in the walls separating
the heart’s chambers, and better general medical care, many more of these children now live to
adulthood (Hijii et al., 1997). Nevertheless, they appear as a group to experience an accelerated
aging process (Hasegawa et al., 1997) and a decline in cognitive abilities (Thompson, 2003). One
recent study reported that of those with Down syndrome who were age 60 and above, more than
50 percent had clinical evidence of dementia (Margallo et al., 2007).

Phenylketonuria

In (PKU), a baby appears normal at birth but lacks a liver enzyme needed to break down
phenylalanine, an amino acid found in many foods. The genetic error results in intellectual
disability only when significant quantities of phenylalanine are ingested, which is virtually
certain to occur if the child’s condition remains undiagnosed (Grodin & Laurie, 2000).

This disorder, which occurs in about 1 in 12,000 births (Deb & Ahmed, 2000), is reversible
(Embury et al., 2007); however, if it is not detected and treated, the amount of phenylalanine in
the blood increases and eventually produces brain damage.

The disorder usually becomes apparent between 6 and 12 months after birth, although symptoms
such as vomiting, a peculiar odor, infantile eczema, and seizures may occur during the early
weeks of life. Often, the first symptoms noticed are signs of intellectual disability, which may be
moderate to severe, depending on the degree to which the disease has progressed. Lack of motor
coordination and other neurological problems caused by the brain damage are also common, and
often the eyes, skin, and hair of untreated patients with PKU are very pale (Dyer, 1999).

The early detection of PKU by examining urine for the presence of phenylpyruvic acid is routine
in developed countries, and dietary treatment (such as the elimination of phenylalanine-
containing foods such as diet soda or poultry) and related procedures can be used to prevent the
disorder (Sullivan & Chang, 1999). With early detection and treatment—preferably before an
infant is 6 months old—the deterioration process can usually be arrested so that levels of
intellectual functioning may range from borderline to normal. A few children suffer intellectual
disability despite restricted phenylalanine intake and other preventive efforts, however. Dietary
restriction in late-diagnosed PKU may improve the clinical picture somewhat, but there is no real
substitute for early detection and prompt intervention (Pavone et al., 1993).

For a baby to inherit PKU, both parents must carry the recessive gene. Thus, when one child in a
family is discovered to have PKU, it is especially critical that other children in the family be
screened as well. Also, a pregnant mother with PKU whose risk status has been successfully
addressed by early dietary intervention may damage her at-risk fetus unless she maintains
rigorous control of phenylalanine intake.

Cranial Anomalies

Intellectual disability can occur in a number of conditions that involve alterations in head size
and shape and for which the causal factors have not been firmly established (Carr et al., 2007).

Macrocephaly (“large-headedness”)

It is a rare condition which involves an increase in the size and weight of the brain, an
enlargement of the skull, visual impairment, convulsions, and other neurological symptoms
resulting from the abnormal growth of glial cells that form the supporting structure for brain
tissue.

Microcephaly (“small-headedness”)

It is defined by a head circumference that is more than three standard deviations below that of
children of the same age and sex and is caused by decreased growth of the cerebral cortex during
infancy (as skull size during infancy is determined by brain growth) (Woods, 2004). Primary
microcephaly refers to decreased brain growth during pregnancy, and secondary microcephaly
refers to decreased brain growth during infancy. Children with microcephaly fall within the
moderate, severe, and profound categories of intellectual disability and most show little language
development and are extremely limited in mental capacity.

A recent review of nearly 700 cases of microcephaly revealed that the cause of the condition was
identified in approximately 60 percent of cases (von der Hagen et al., 2014). Approximately half
of these were caused by genetic factors, 45 percent were the result of brain damage in utero (e.g.,
due to factors such as maternal disease or birth complications), and 3 percent were caused by
brain damage after birth. It is important to note that the cause of microcephaly is completely
unknown in about 40 percent of cases, and so much additional research is needed to better
understand this condition.

Hydrocephaly

It is a relatively rare disorder in which the accumulation of an abnormal amount of cerebrospinal

fluid within the cranium causes damage to the brain tissues and enlargement of the skull
(Materro et al., 2001). In congenital cases, the head either is already enlarged at birth or begins to
enlarge soon thereafter, presumably as a result of a disturbance in the formation, absorption, or
circulation of the cerebrospinal fluid. The disorder can also arise in infancy or early childhood
following the development of a brain tumor, subdural hematoma, meningitis, or other conditions.
In these cases, the condition appears to result from a blockage of the cerebrospinal pathways and
an accumulation of fluid in certain brain areas.

The clinical picture in hydrocephaly depends on the extent of neural damage, which in turn
depends on the age at onset and the duration and severity of the disorder.

In chronic cases, the chief symptom is the gradual enlargement of the upper part of the head out
of proportion to the face and the rest of the body. Although the expansion of the skull helps
minimize pressure on the brain, serious brain damage occurs nonetheless. This damage leads to
intellectual impairment and to such other effects as convulsions and impairment or loss of sight
and hearing. The degree of intellectual impairment varies, being severe or profound in advanced
cases.

Hydrocephaly can be treated by a procedure in which shunting devices are inserted to drain
cerebrospinal fluid.

With early diagnosis and treatment, this condition can usually be arrested before severe brain
damage has occurred (Duinkerke et al., 2004). Even with significant brain damage, carefully
planned and early interventions that take into account both strengths and weaknesses in
intellectual functioning may minimize disability (Baron & Goldberger, 1993).

Summary
• Historically, intellectual disability has been defined by significant cognitive deficits,
typically established by the testing of IQ and adaptive behaviors. There are no laboratory
tests for ID; however, many specific causes and genetic factors for ID can be identified
through laboratory tests.

• Males are more likely than females to be diagnosed with ID. Poverty is a risk factor for
ID, especially for mild ID.

• The functional impairments associated with ID are generally lifelong. However, there are
functional supports that may enable an individual with ID to function well and participate
in society.

• As a diagnostic category, IDs include individuals with a wide range of intellectual

functional impairments and difficulties with daily life skills. The levels of severity of
intellectual impairment and the need for support can vary from profound to mild.

• Comorbidities, including behavioral disorders, are common.