topic selection: Mental Retardation and the article is on file 2-3 pages 1) Follow these guidelines when completing this assignment. Speak with your faculty member if you have questions. a. Select

Background . Many of the nongenetic causal risk factors of intellectual d isability (ID) can be prevented if they are identi5ed early.

9ere is paucity on information regarding potential risk factors associated with this condition in Kenya. 9is study aimed to establish risk factors associated with severity of nongenetic intellectual disability (ID) among children presenting with this condition at Kenyatta National Hospital (KNH). Methods. A hospital-based cross-sectional study was conducted over the period between March and June 2017 in pediatric and child/youth mental health departments of Kenyatta National Hospital (KNH), Kenya. It included children aged 2–1\b years diagnosed with ID without underlying known genetic cause. Results. Of 67 patients with nongenetic ID, 24% had mild ID, 40% moderate, 23% severe-profound, and 10% unspeci5ed ID. 9e mean age of children was \f.b ( ±3.b) years. Male children were predominant (b2%). 9ree independent factors including “labor complications” [AOR = 6.4\f, 6\f% CI = 1.23–113.26, ≤ = 0.036], “admission to neonatal intensive care unit” [AOR = \b.06, 6\f% CI = 2.11–31.07, ≤ = 0.002], and “cerebral palsy” [AOR = 21.1\b, CI = 4.1\b–107.40, ≤ ≥ 0.001] were signi5cantly associated with increased risk of severe/profound nongenetic ID. Conclusion . 9e present study 5ndings suggest that perinatal compli cationsaswellaspostnatalinsultsareassociatedwith increased risk of developing severe-profound intellectual disability, implying that this occurrence may be reduced with appropriate antenatal, perinatal, and neonatal healthcare interventions. 1. Introduction Intellectual disability (ID), formerly known as “mental retar- dation,” is a condition characterized by signi5cant below average intellectual functioning and impairment in adaptive behaviors, manifested before age 1\b years. 9e degrees of intellectual disability include mild, moderate, and severe and profound intellectual disability [1, 2]. Intellectual disability is a public concern due to the number of people alected by this condition with consideration of the increased demand of specialized medical, psychosocial, and educational services required to improve their quality of life [3]. According to recent reviews and meta-analysis, globally, about 1% of general population is alected by intellectual disability [4, \f]. Child/adolescent population has higher prevalence (1\b.30/1000) than the adult population (4.64/1000) [\f]. Fur- thermore, it is estimated that about 1% of children between the ages 3 and 10 years are alected by intellectual disability worldwide [b].

Intellectual disability is associated with multicausal risk factors including genetic and nongenetic or acquired causes.

But in some cases, the aetiology is unknown [7]. Genetic factors such as chromosomal abnormalities, inherited genetic traits, and single gene disorders are the major causes accounting for 30% to \f0% of all intellectual disability cases.

Nongenetic causes comprise prenatal, perinatal, postnatal, and environmental factors [\b]. Most prevalent reported nongenetic prenatal risk factors include maternal conditions such as asthma, diabetes, hypertension, renal conditions, and epilepsy [\b, 6]. Other factors are tobacco or alcohol use, Hindawi Neurology Research International Volume 2018, Article ID 6956703, 11 pages https://doi.org/10.1155/2018/6956703 2Neurology Research International parental advanced age, low maternal education, multiparity, and maternal black race [\b]. Main perinatal factors are low birth weight, preterm birth, birth complications, and perinatal infections [\b, 10]. Postnatal infections, exposure to toxicants like lead or mercury, developmental disorders, central nervous system malignancies, and chronic severe malnutrition have been reported as postnatal factors [7, \b].

9ese associated factors of intellectual disability are in inter- active complexity with environmental factors and sociode- mographic and socioeconomic characteristics of population [6, 11]. It is that many of the factors and causes of nongenetic intellectual disability are preventable, if early detection is done and timely interventions are taken [b, 12]. Most of the studies regarding risk factors of intellectual disability have been conducted in developed countries, with limited information from developing countries [3]. In Kenya, information on incidence, prevalence, and associated factors of intellectual disability is scarce. Studies are needed to establish more information on the burden of this condition in Kenya. Furthermore, little is known on the magnitude of potential nongenetic risk factors contributing to development of intellectual disability among children alected with this condition in Kenya. Given the paucity of epidemiological information on the causal risk factors associated with intel- lectual disability in Kenya, the aim of this study was to explore potential risk factors associated with development of severe/profound nongenetic intellectual disability among children presenting with this condition at Kenyatta National Hospital (KNH).

2. Methods 2.1. Study Setting and Design. 9is study was a hospital- based, descriptive cross-sectional study conducted over period from March, 2017, to June, 2017, in the pediatric and mental health departments of Kenyatta National Hospital (KNH). KNH is the biggest national referral hospitals in Kenya located in Nairobi, capital city of Kenya. 9is hospital is located in Upper-Hill area along hospital road, ol-Ngong’ road, Nairobi. Its total bed capacity is 2000. KNH has \f0 inpatient wards and dilerent outpatient and specialized clinics, among them are pediatric department and mental health department. 9e mental health department provides dilerent services, among them are child psychiatric clinic and youthmentalhealthclinic,bothworkingonoutpatientbasis.

Patients with mental health problems requiring inpatient care were being admitted to the general pediatric-medical wards.

At KNH, children with intellectual disability with age of up to 12 years are followed up at the child psychiatric clinic and at pediatric neurologic outpatient clinic while the adolescents aged from 13 years are followed up at the youth mental health clinic.

2.2. Study Participants. Children/adolescents between the ages of 2 and 1\b years and diagnosed with intellectual disabil- ity without underlying known genetic cause were recruited consecutively from pediatric wards, pediatric outpatient clin- ics, and mental health department of KNH, over a period of 4 months. 9e age group (2 to 1\b years) of children was chosen based on the fact that DSM-\f (Diagnostic and Statistical Manual of Mental Disorders, Fieh Edition) criteria specify that diagnosis of intellectual disability is made during devel- opment period, before age of 1\b years [1]. Participants were selected aeer the con5rmation of the diagnosis of intellectual disability by a pediatrician and clinical psychologist. Children who were identi5ed with genetic conditions known to lead to intellectual disability were excluded from the study. 9ose who were critically ill were also excluded from the study.

Using purposive sampling method, a total of 67 patients with nongenetic intellectual disability were consecutively recruited as study participants over the 4-month period of data collection.

2.\b. Data Collection and Analysis.

Data was collected from consenting parents and through desk reviews of patient 5les.

9e details on degree of intellectual disability were obtained from the patient’s medical records. Using semistructured questionnaire, data on child and parental sociodemographic characteristics, pregnancy, birth history, postnatal history, medical and nutritional histories, and environmental expo- sure were collected from the child’s parents. 9is was sup- plemented by data from desk reviews. Information on the comorbid conditions was also checked from the medical records. Data was analyzed using Statistical Package for Social Sciences (SPSS) 23.0 version (IBM SPSS Statistics v23). 9e relationships between the individual factors and severity of intellectual disability were evaluated using crude odds ratio for bivariate and adjusted odds ratio for multivariate logistic regression models. Signi5cance of statistical association was tested using con5dence interval (CI) of 6\f% and ≤value < 0.0\f.

2.4. Ethical Consideration. 9e ethical approval and per- missiontoconductthestudywasgrantedbytheKeny- atta National Hospital-University of Nairobi Ethics and Research Committee (KNH/UON-ERC) (Approval number:

P6b1/12/201b). 9e permission to collect data was provided by the Kenyatta National Hospital (KNH) administration.

Written parental permission/informed consent was obtained from the parents of children with intellectual disability attending KNH. Assent was also obtained from adolescent without profound intellectual disability. 3. Results \b.1. Sociodemographic Characteristics of the Children and Parents. Of 67 children/adolescents included in the study, themeanagewas\f.byears(SD± 3.b years), majority were males(b1.6%),andmost(74.2%)werelivingwithbothoftheir parents. Table 1 provides details on the sociodemographic characteristics of the children. Table 2 shows the distribution of selected sociodemo- graphic and socioeconomic characteristics among the par- ents. Majority of children’s parents (mothers (\b2.\f%) and fathers (\f\b.7%)) were in middle ages between 21 and 3\f years. 9e highest percentage (47.4%) of mothers were casual workers and only 31% were regularly employed, while about Neurology Research International3 T 1: Distribution sociodemographic characteristics among the children.

Va r i a b l e =97% Age in years 2to3 3132 4to\f 3132 bandabove 3\f3b Mean ( ±SD) = \f.b ( ±3.b) Gender Male b0b2 Female 373\b Family setup Both parents 7274 Single mother 2324 Orphan/adopted 11 Abandoned 11 Number of children in the family 1child \f\f\f7 2 children 2\f2b 3 children 1414 4 children 33 Siblings’ history of intellectual disability Ye s \f\f No 626\f Degree of intellectual disability (ID) Mild ID 2324 Moderate ID 3640 Severe/profound ID 2223 Unspeci5ed ID 1313 21.b% were unemployed. More than half of the fathers were having regular employment. Majority of the mothers (\f7.7%) and fathers (\f\b.7%) had attained secondary school education.

26.3% of fathers were smokers. Majority \f3.b% of parents reported earning between 21,000 and \f0.000 Kenyan Shillings as their monthly family income.

\b.2. Bivariate Analysis of Factors Associated with Severity of Nongenetic Intellectual Disability among Children. 9ere was more proportion of severe/profound intellectual disability among children of single mothers (3\b.6%) compared to those children raised by both parents (23.4%). However, this was not statistically signi5cant [OR = 2.0\b; 6\f% CI = 0.b6–b.31; ≤ = 0.196].9estudyshowednosigni5cantassociation between the other sociodemographic characteristics of chil- dren and severity of intellectual disability (Table 3). Table 4 shows the relationship between sociodemo- graphic and economic characteristics of parents and severity of nongenetic intellectual disability. Even though mothers aged above 3\f years had increased proportion of children with severe/profound nongenetic intellectual disability (4b.7%) compared to those aged between 21 and 3\f years (21.7%), this was not statistically signi5cant [OR = 3.1\f; 6\f% CI = 0.6\b–10.06; ≤ = 0.053]. Children of unemployed mothers T 2: Selected sociodemographic and economic characteristics of mothers.

Va r i a b l e =97% Age of the mother 21–3\f years \b0 \b2.\f 3b years 17 17.\f Age of the mother at the time of child’s birth Below 20 years b b.2 21–3\f years \b4 \bb.b 3b years 7 7.2 Age of the father 21–3\f years \f4 \f\b.7 3b years 3\b 41.3 Missing \f Age of the father at the time of birth of the child 21–3\f years b\b 73.6 3b years 24 2b.1 Missing \f Highest level of education of the mother Primary level 31 32 Secondary level \fb \f7.7 College/university Level 10 10.3 Highest level of education of the father No formal education 2 2.2 Primary level \b \b.7 Secondary level \f4 \f\b.7 College/university Level 2\b 30.4 Missing \f Occupation of the mother Regular employment 30 30.6 Casual employment 4b 47.4 Unemployed 21 21.b Occupation of the father Regular employment 4\b \f2.2 Casual employment 42 4\f.7 Unemployed 2 2.2 Missing \f Whether the father smokes Ye s 2 7 2 6 . 3 No b\f 70.7 Missing \f Average monthly income in the family in Kenyan Shillings More than \f0,000 4 4.1 21,000 to \f0,000 \f2 \f3.b 11,000 to 20,000 3\b 36.2 Less than 10,000 3 3.1 4Neurology Research International T 3: Relationship between sociodemographic characteristics of children and severity of intellectual disability. Va r i a b l e sSevere/profound Mild/moderate OR6\f% CI 2test % %L ow er Upp er ≤value Age in years 2 to 3 \b 42.1% 11 \f7.6% 2.10 0.b4 b.\b7 0.216 4 to \f \f 1b.7% 2\f \b3.3% 0.\f\b 0.17 1.6b 0.376 b and above 6 2\f.7% 2b 74.3% 1.00 Gender Male 12 23.\f% 36 7b.\f% 0.71 0.2b 1.60 0.460 Female 10 30.3% 23 b6.7% 1.00 Family setup Both parents 1\f 23.4% 46 7b.b% 1.00 Single mother 7 3\b.6% 11 b1.1% 2.0\b 0.b6 b.31 0.16b Number of children in the family 1 child 6 16.1% 3\b \b0.6% 1.00 2 children b 2\b.b% 1\f 71.4% 1.b6 0.\f1 \f.\f7 0.3\b6 3-4 children 7 43.\b% 6 \fb.3% 3.2\b 0.6b 11.16 0.0\f7 Siblings’ history of intellectual disability Yes 1 2\f.0% 3 7\f.0% 0.64 0.06 6.\f0 0.6\fb No 21 2b.3% \f6 73.\b% 1.00 OR = odds ratio; CI = con5dence interval; 2=Chi-square. and those of fathers with regular employment were hav- ing increased odds of severe/profound intellectual disability compared to others; however, this was not statistically sig- ni5cant [OR = 2; 6\f% CI = 0.\fb–7.06;≤ = 0.283and OR = 2.b0; 6\f% CI = 0.\b2–\b.20; ≤ = 0.096, resp.]. Similarly, there was no signi5cant association between severity of nongenetic intellectual disability and other parental sociodemographic characteristics. 9e relationship between pregnancy-related factors and severity of intellectual disability was analyzed. On the variable “took any drugs during pregnancy,” there is a signi5cant increase in the number of children with mild/moderate intellectual disability in mothers who denied having taken drugs during pregnancy. In the case of the severe/profound intellectual disability, the number of cases was the same to the mothers who did not take drugs. 9ere were more children with intellectual disability, born of mothers who had indicated “living in environment where people smoke” than those who reported otherwise, and this was signi5cant [OR = 0.1\b;6\f%CI:0.0b–0.\f\f; P=0.001](Table\f).

Table b shows the relationship between birth history of the children and severity of intellectual disability. Children born through labor complications had signi5cantly more proportion of severe/profound intellectual disability (36.1%) [OR = \f.4b; 6\f% CI = 1.bb–1\b.02; ≤ = 0.003]comparedto those children without labor complications (10.\f%). 9ere was signi5cantly higher proportion of severe/profound intel- lectual disability among children delivered by caesarean section (\f0.0%) [OR = 4.b4; 6\f% CI = 1.b1–13.3\b; ≤= 0.005] than those children delivered through spontaneous vaginal delivery (17.7%) and this was statistically signi5cant.

Apgar score at birth was also signi5cantly associated with severity of intellectual disability among children. Children withApgarscorelowerthan7outoftensigni5cantlysulered severe/profound intellectual disability (3\b.b%) [OR = 4.41; 6\f% CI = 1.44–13.4b; ≤ = 0.007]morethanchildrenwho scored above 7 out of ten (12.\f%). Similarly children who were resuscitated at birth had signi5cantly higher proportion of severe/profound intellectual disability (40.0%) [OR = 4.22; 6\f% CI = 1.4\f–12.26; ≤ = 0.006]thanthosewhowerenot (13.b%). 9ere was signi5cantly increased proportion of severe/profound intellectual disability among children who had any neonatal di culties (3b.\f%) [OR = \f.\f7; 6\f% CI = 1.46–20.7\f; ≤ = 0.006] than those children without (6.4%). Children who were admitted to NICU during neonatal period had signi5cantly more proportion of severe/profound intellectual disability (41.6%) [OR = b.bb; 6\f% CI = 2.01–22.03; ≤ = 0.001] compared to those children that have never been admitted in NICU during neonatal period (6.\b%). Similarly, those children with neonatal breathing di culties (37.\b%) had higher proposition of severe/profound intellectual disability than others without neonatal breathing di culties (17.0%) and this was signi5cant [OR = 2.67; 6\f% CI = 1.0\b–\b.1\f; ≤ = 0.031]. 9ere was also signi5cant association between neonatal feeding di culties and severe/profound intellectual disability where children with neonatal feeding di culties had signi5cantly more severe/profound intellectual disability (\f0.0%) [OR = 3.\bb; 6\f% CI = 1.23–12.06; ≤ = 0.016] compared to those children without (20.b%). No statistical signi5cant relationship was found in the factors such as neonatal seizures, neonatal infection, and neonatal jaundice (Table 7). 9ere was no statistically signi5cant association observed between infant and childhood medical and severity of intellectual disability among the children (Table \b). Neurology Research International\f T 4: Association between sociodemographic and economic characteristics of mothers and severity of intellectual disability. Va r i a b l e sSevere/profound Mild/moderate OR6\f% CI 2test % %L ow er Upp er ≤value Age of the mother 21–3\f years 1\f 21.7% \f4 7\b.3% 1.00 3b years 7 4b.7% \b \f3.3% 3.1\f 0.6\b 10.06 0.0\f3 Age of the mother at the time of birth of the child Below 20 years 2 33.3% 4 bb.7% 1.2\f 0.12 13.24 0.\b\f3 21–3\f years 1\b 2\f.4% \f3 74.b% 0.\b\f 0.1\f 4.7b 0.\b\f2 >3b years 2 2\b.b% \f 71.4% Age of the father 21–3\f years \b 17.4% 3\b \b2.b% 0.44 0.1\f 1.2b 0.120 >3b years 11 32.4% 23 b7.b% 1.00 Age of the father at the time of birth of the child 21–3\f years 12 20.7% 4b 76.3% 0.\fb 0.16 1.b\b 0.26b >3b years 7 31.\b% 1\f b\b.2% 1.00 Highest level of education of the mother Primary level \b 30.\b% 1\b b6.2% 0.74 0.14 3.\b\b 0.722 Secondary level 11 22.0% 36 7\b.0% 0.47 0.10 2.2\b 0.346 College/university Level 3 37.\f% \f b2.\f% 1.00 Highest level of education of the father Primary level 2 2\b.b% \f 71.4% 0.60 0.14 \f.bb 0.611 Secondary level 6 20.0% 3b \b0.0% 0.\fb 0.16 1.70 0.306 College/university Level \b 30.\b% 1\b b6.2% 1.00 Occupation of the mother Regular employment \b 30.\b% 1\b b6.2% 1.00 Casual employment b 14.b% 3\f \b\f.4% 0.36 0.12 1.2\b 0.120 Unemployed \b 47.1% 6 \f2.6% 2.00 0.\fb 7.06 0.2\b3 Occupation of the father Regular employment 13 30.2% 30 b6.\b% 2.b0 0.\b2 \b.20 0.06b Casual employment \f 14.3% 30 \b\f.7% 1.00 Unemployed Whether the father smokes Yes 3 12.0% 22 \b\b.0% 0.33 0.06 1.27 0.06b No 1b 26.1% 36 70.6% 1.00 Average monthly income in the family (in KES) <21,000 \b 23.\f% 2b 7b.\f% 0.76 0.26 2.1b 0.b47 21,000 and more 14 2\b.0% 3b 72.0% 1.00 OR = odds ratio; CI = con5dence interval; 2=chi-square. Table 6 shows the bivariate analysis of relationship between preexisting/comorbid and severity of intellectual disability. Children with cerebral palsy were signi5cantly more likely to suler severe/profound intellectual disability [OR = 1\b.1\b; 6\f% CI = 3.\b\b–\b\f.14; ≤ ≥ 0.001]comparedto those children without. 9ere was no statistically signi5cant associationobservedinothervariables.

\b.\b. Multivariate Analysis of Factors Associated with Severity of Nongenetic Intellectual Disability among Children. Binary logistic regression analysis was applied to identify the vari- ables independently associated with severity of intellectual disability among children aged 2 to 1\b years. Eleven (11) factors were considered in the analysis including labor com- plications, mode of delivery, APGAR score at birth, whether the baby was resuscitated at birth, any neonatal di culties, whether the baby was admitted in NICU, neonatal breath- ing di culty, neonatal feeding di culties, cerebral palsy, using drugs during pregnancy, and living in environment where people smoke. Upon 5tting these factors using binary logistic regression and by specifying “backward LR”method with removal at ≤ < 0.05, three (3) factors remained in the 5nal analysis (Table 10). Severe/profound intellectual disability was about 10 times more among children with labor complications during birth [AOR = 6.4\f; 6\f% CI = 1.23–113.26; ≤ = 0.036] compared to those children without bNeurology Research International T \f: Relationship between pregnancy-related factors and severity of intellectual disability. Va r i a b l e sSevere/profound Mild/moderate OR6\f% CI 2test % %L ow er Upp er ≤value Attending ANC during pregnancy of the child Yes 22 27.2% \f6 72.\b% 1.00 No 0 0.0% 3 100.0% UD UD UD 0.263 Frequency of attending ANC 1-2 times 3 1b.7% 1\f \b3.3% 0.4b 0.12 1.76 0.2\fb 3-4 times 16 30.2% 44 b6.\b% 1.00 Took any drugs during pregnancy Yes 11 47.\b% 12 \f2.2% 4.17 1.4b 11.\b7 0.006 No 11 1\b.0% \f0 \b2.0% 1.00 Smoking during pregnancy Yes 1 10.0% 6 60.0% 0.2\b 0.03 2.3\f 0.21\f No 21 2\b.4% \f3 71.b% 1.00 Living in environment where people smoke Yes 12 1\b.2% \f4 \b1.\b% 0.1\b 0.0b 0.\f\f 0.001 No 10 \f\f.b% \b 44.4% 1.00 Using alcohol during this pregnancy Yes \f 3\f.7% 6 b4.3% 1.73 0.\f1 \f.\b\b 0.37\f No 17 24.3% \f3 7\f.7% 1.00 OR = odds ratio; CI = con5dence interval; 2=chi-square;UD=unde5ned. labor complications. Children who were admitted to nursery during neonatal period had \b times more likely to have severe/profound intellectual disability [AOR = \b.06; 6\f% CI = 2.11–31.07;≤ = 0.002] compared to those children that have been never admitted in nursery during neonate.

Children with cerebral palsy were 21-fold more likely to have severe/profoundintellectualdisability[AOR=21.1\b;6\f%CI =4.1\b–107.40; ≤ ≥ 0.001] compared to those children without cerebral palsy.

4. Discussion 9e study 5ndings indicate that mean age of study population was \f.b years with a standard deviation of 3.b years. Male children were more alected than females; this 5nding is in agreement with the results from other studies which reported male predominance [4, \f, 13]. Current 5ndings show that high proportion (40%) of children were sulering moderate intellectual disability. 9is result agrees with a similar study conducted in India [14] where 40% of children had moderate intellectual disability. 9is high proportion of moderate intellectual disability could be attributed to referrals as KNH serves as a referral hospital. Children with moderate intellec- tual disability tend to have remarkable limitations in meeting expected standards of personal independence and social responsibility in dilerent aspects of daily life, especially when they start school. 9erefore, when child starts to show slow academic achievements, he/she is referred for psychological evaluation. Logistic regressions analysis did not reveal any signi5cant association of child sociodemographic variables (including age, gender, family set-up, and number of children in family) and severity of intellectual disability. 9is result is similar to the 5ndings of a study done in India [14] which examined correlation of sociodemographic variables of patients with intellectual disability and types of intellectual disability.

In the present study, mothers aged 3\f years and above were having increased proportion of children with severe- profound intellectual disability compared to those aged 21–3\f years. However, there was no statistically signi5cant relationship between parental age and severity of intellec- tual disability. An early study done by Drews et al. [1\f] and a recent systemic review and meta-analysis done by Huang et al. [\b] reported a positive association between advanced parental age and intellectual disability though these studies were combining both genetic and nongenetic cases.

9e present study included only children with intellectual disability that is considered nongenetic, with exclusion of thosewhowerehavinggeneticdisordersknowntoleadto intellectual disability. 9is fact may explain the predominance ofparentswithmiddleagesinthisstudy.Norelationshipwas revealed between parental level of education and severity of intellectual disability. However, a review and meta-analysis by Huang et al. reported positive association of lack of maternal education with intellectual disability [\b]. Moreover, one of the 5ndings from a study carried out in Utah, America, indicated asigni5cantassociationbetweenintellectualdisability(with exclusion of genetic cases) and maternal education though that was not signi5cant on paternal education [10]. Even though socioeconomic status of the parents did not show any statistically signi5cant relationship with the severity of intellectual disability, great proportion of children with severe-profound intellectual disability were found among mothers who were unemployed compared to those with Neurology Research International7 T b: Association between birth history of the children and severity of intellectual disability. Va r i a b l e sSevere/profound Mild/moderate OR6\f% CI 2test % %L ow er Upp er ≤value Place of deliver for the baby Health facility 22 2\b.b% \f\f 71.4% 1.00 Home 0 0.0% 7 100.0% UD UD UD 0.100 Gestational age when the child born From 33–37 weeks 7 31.\b% 1\f b\b.2% 1.43 0.46 4.17 0.\f10 Over 37 weeks 1\f 24.b% 4b 7\f.4% 1.00 Labor complications Yes 1\b 36.1% 2\b b0.6% \f.4b 1.bb 1\b.02 0.003 No 4 10.\f% 34 \b6.\f% 1.00 Mode of delivery Spontaneous vaginal delivery 11 17.7% \f1 \b2.3% 1.00 Cesarean section 11 \f0.0% 11 \f0.0% 4.b4 1.b1 13.3\b 0.005 Birth weight <2.\f kg \f 27.\b% 13 72.2% 1.11 0.34 3.\f7 0.\bb3 2.\f Kg and above 17 2\f.\b% 46 74.2% 1.00 Apgar score at birth <7/10 (did not cry) 17 3\b.b% 27 b1.4% 4.41 1.44 13.4b 0.007 >7/10 (cried immediately) \f 12.\f% 3\f \b7.\f% 1.00 Whether the baby was resuscitated at birth Yes 1b 40.0% 24 b0.0% 4.22 1.4\f 12.26 0.006 No b 13.b% 3\b \bb.4% 1.00 OR = odds ratio; CI = con5dence interval; 2=chi-square;UD=unde5ned. T 7: Association between neonatal medical history o f the children and severity of intellectual disability. Va r i a b l e sSevere/profound Mild/moderate OR6\f% CI 2test % %L ow er Upp er ≤value Any neonatal di culties Yes 16 3b.\f% 33 b3.\f% \f.\f7 1.46 20.7\f 0.006 No 3 6.4% 26 60.b% 1.00 Whether the baby was admitted in NICU Yes 1\b 41.6% 2\f \f\b.1% b.bb 2.01 22.03 0.001 No 4 6.\b% 37 60.2% 1.00 Neonatal breathing di culty Yes 14 37.\b% 23 b2.2% 2.67 1.0\b \b.1\f 0.031 No \b 17.0% 36 \b3.0% 1.00 Neonatal seizures Yes b 30.0% 14 70.0% 1.26 0.42 3.61 0.b\f7 No 1b 2\f.0% 4\b 7\f.0% 1.00 Neonatal infection Yes 4 20.0% 1b \b0.0% 0.b4 0.16 2.17 0.471 No 1\b 2\b.1% 4b 71.6% 1.00 Neonatal jaundice Yes 3 27.3% \b 72.7% 1.07 0.2b 4.44 0.630 No 16 2b.0% \f4 74.0% 1.00 Neonatal feeding di culties Yes \b \f0.0% \b \f0.0% 3.\bb 1.23 12.06 0.016 No 14 20.b% \f4 76.4% 1.00 OR = odds ratio; CI = con5dence interval; 2=chi-square;UD=unde5ned. \bNeurology Research International T \b: Association of infant and childhood medical history with severity of intellectual disability. Va r i a b l e sSevere/profound Mild/moderate OR6\f% CI 2test % %L ow er Upp er ≤value Immunization history Fully immunized 20 2\f.0% b0 7\f.0% 1.00 Not fully immunized 2 \f0.0% 2 \f0.0% 3.00 0.40 22.71 0.2\b7 Su er from any disease Yes 10 22.7% 34 77.3% 0.b6 0.2b 1.\b2 0.446 No 12 30.0% 2\b 70.0% Histor y of meningitis Yes b 20.0% 24 \b0.0% 0.\f6 0.20 1.73 0.33b No 1b 26.b% 3\b 70.4% Histor y of encephalitis Yes 0 0.0% b 100.0% UD UD UD 0.130 No 22 2\b.2% \fb 71.\b% 1.00 Histor y of cerebral malaria Yes 2 bb.7% 1 33.3% b.10 0.\f3 70.60 0.104 No 20 24.7% b1 7\f.3% 1.00 Histor y of head injur y Yes 2 1\b.2% 6 \b1.\b% 0.\f6 0.12 2.6b 0.\f71 No 20 27.4% \f3 72.b% 1.00 Histor y of severe malnutrition Yes 3 23.1% 10 7b.6% 0.\b2 0.20 3.31 0.7\b1 No 16 2b.\b% \f2 73.2% 1.00 Breastfeeding history Breastfeed <1 month 1 33.3% 2 bb.7% 1.14 0.06 14.7\b 0.616 Breastfeed 1–24 months 13 22.\b% 44 77.2% 0.b\b 0.23 1.66 0.477 Breastfeed >24 months 7 30.4% 1b b6.b% 1.00 OR = odds ratio; CI = con5dence interval; 2=chi-square. employment. Comparable 5ndings were reported in Indian study in which no signi5cant association of intellectual disability severity and socioeconomic status was found [14]. A cohortstudydoneinBrazilreportedalsolackofassociation between socioeconomic status and groups with intellectual disability[1b].Onthecontrary,astudydoneinAustralia found positive relationship of socioeconomic disadvantage and increased risk of intellectual disability [17]. Probably, this dilerence may be due to the fact that the latter studies used dilerent methods and large population compared to the present study.

Tobacco smoking and use of alcohol during pregnancy was found to be a major risk factor for developing intellectual disability in the olspring [4, \b]. In this study, no association was found between alcohol use or tobacco smoking during pregnancy and severity of intellectual disability. O’Leary et al., in their population based study to examine the association of maternal alcohol use disorder and intellectual disability, found that children of mothers with an alcohol-related diag- nosis recorded during pregnancy had three times increased risk of intellectual disability than others [1\b]. Unexpectedly, inverse association with severity of intellectual disability was found in mothers who reported living in the environment where people smoke. In this study, no signi5cant association was found between severity of intellectual disability and place of delivery or gestational age. Bivariate analysis demonstrated signi5- cant association of delivery through caesarean section and intellectual disability severity, though this lost its signi5cance in multivariate analysis. 9is quietly corroborate results reported by Langridge et al. in which there was an increased risk of intellectual disability (ID) in children born via cae- sarean section compared to those delivered through a spon- taneous vaginal birth [16] and the study by Bilder et al. which found signi5cant association of primary/repeat caesarean sections and intellectual disability [10]. 9e present study did not establish what are the indications of caesarean sections.

It is however di cult to conclude from this study whether merely caesarean section as mode of delivery is a risk factor for intellectual disability. It is therefore necessary to further examine the relationship between the various indications of caesarean section with the incidence of intellectual disability. 9e children born through complicated labor had increased likelihood of severe/profound intellectual disabil- ity; they had about 10 times risk of severe/profound intellec- tual disability compared to others without history of labor complications. 9is compares with the 5ndings from other studies that report positive and signi5cant association of Neurology Research International6 T 6: Relationship between pre-existing/co-morbid and severity of intellectual disability. Va r i a b l e sSevere/profound Mild/moderate OR6\f% CI 2test % %L ow er Upp er ≤value Cerebral palsy Yes 20 47.b% 22 \f2.4% 1\b.1\b 3.\b\b \b\f.14 ≥0.001 No 2 4.\b% 40 6\f.2% 1.00 Convulsive disorders Yes 16 27.\f% \f0 72.\f% 1.\f2 0.36 \f.66 0.\f47 No 3 20.0% 12 \b0.0% 1.00 Cardiovascular disease Yes 1 \f0.0% 1 \f0.0% 2.61 0.17 4\b.\f3 0.43\b No 21 2\f.b% b1 74.4% 1.00 Asthma Yes 1 \f0.0% 1 \f0.0% 2.61 0.17 4\b.\f3 0.43\b No 21 2\f.b% b1 74.4% 1.00 Pneumonia Yes b 2b.1% 17 73.6% 0.66 0.33 2.6b 0.6\b6 No 1b 2b.2% 4\f 73.\b% 1.00 Malnutrition Yes 3 33.3% b bb.7% 1.47 0.34 b.4\b 0.b0b No 16 2\f.3% \fb 74.7% Rickets Yes 1 2\f.0% 3 7\f.0% 0.64 0.06 6.\f0 0.6\fb No 21 2b.3% \f6 73.\b% 1.00 Autism Spectrum Disorder (ASD) Yes 1 10.0% 6 60.0% 0.2\b 0.03 2.3\f 0.21\f No 21 2\b.4% \f3 71.b% 1.00 Attention De\fcit/Hyperactivity Disorder (ADHD) Yes 2 22.2% 7 77.\b% 0.76 0.1\f 4.10 0.774 No 20 2b.7% \f\f 73.3% OR = odds ratio; CI = con5dence interval; 2=chi-square. labor and delivery complications and degrees of intellectual disability [\f, 16]. Labor and delivery complications lead to complications such fetal distress and birth asphyxia and intracranial hemorrhage leading to poor neonatal outcomes which later alect child brain development due to damage resulting from hypoxia related to these complications.

Low Apgar score is risk factor for intellectual disability [10]. In this study, bivariate analyses, children with histories of lower Apgar score, neonatal complications, and resuscita- tion at birth had increased risks of having severe-profound intellectual disability compared to their counterparts without these histories, though this association lost its signi5cance aeer multivariate regressions analysis. 9e histories of peri- natal di culties and neonatal resuscitation required at birth weredistinctlyshowntobeassociatedwithincreasedin intellectual disability [16]. Low Apgar scores indicate poor birth outcomes with need of neonatal resuscitation, thus increasing probability of neonatal sequelae which expose the child to develop intellectual disability during development period. 9is is supported by evidence from cohort study conducted in Brazil where 13.2% of intellectual disability caseswereattributedtoneonatalsequelae[1b]. Karametal.notedthatsomeoftheneonatalcomplica- tions and problems may cause neonatal sequelae resulting in intellectual disability [1b]. In this study, children with history of neonatal breathing di culty and those with neonatal feeding di culties, respectively, had three and four odds of having severe-profound intellectual disability compared to their counterparts. However, these associations were not signi5cant in multivariate logistic regressions. Children who were admitted to neonatal intensive care unit (NICU) were having \b times risk of having severe-profound intellectual dis- ability compared to their counterparts not admitted in NICU.

9is could be attributed to the fact that labor complications lead to birth di culties and neonatal complications which increase the probability of being admitted in neonatal inten- sive care unit. Being born with birth complications suggests increased risk of debilitating conditions which predict likeli- hood to be alected with intellectual disability. Maulik et al.

indicated neonatal infections among the common postnatal causes [\f]. 9e present study did not 5nd any signi5cant association between severity of intellectual disability and medical histories of neonatal seizures, neonatal infection, and neonatal jaundice. 10Neurology Research International T 10: Factors associated with severity of intellectual disability among children. Va r i a b l eC O R6\f% CI ≤value AOR 6\f% CI ≤value Lower Upper Lower Upper Labor complications Yes \f.4b 1.bb 1\b.02 0.003 6.4\f 1.23 113.26 0.036 No 1.00 1.00 Mode of delivery Spontaneous vaginal delivery 1.00 1.00 Cesarean section 4.b4 1.b1 13.3\b 0.00\f 3.4\b 0.\f6 20.\fb 0.1b6 APGAR score at birth <7/10 4.41 1.44 13.4b 0.007 6.1\f 0.47 176.\f4 0.14\f >7/10 1.001.00 Whether the baby was resuscitated at birth Yes 4.22 1.4\f 12.26 0.00b 0.0\b 0.00 3.37 0.1\bb No 1.001.00 Any neonatal di culties/complications at birth Yes \f.\f7 1.46 20.7\f 0.00b 2.13 0.10 4b.b1 0.b31 No 1.001.00 Whether the baby was admitted in NICU Yes b.bb 2.01 22.03 0.001 \b.06 2.11 31.07 0.00\b No 1.001.00 Neonatal breathing di culty Yes 2.67 1.0\b \b.1\f 0.031 0.2b 0.02 2.62 0.272 No 1.001.00 Neonatal feeding di culties Yes 3.\bb 1.23 12.06 0.01b 0.\f2 0.06 3.23 0.4\bb No 1.001.00 Cerebral palsy Yes 1\b.1\b 3.\b\b \b\f.14 0.001 21.1\b 4.1\b 107.40 ≥0.001 No 1.001.00 Took any drugs during pregnancy Yes 4.17 1.4b 11.\b7 0.00b 3.62 0.70 21.67 0.120 No 1.001.00 Living in environment where people smoke Yes 0.1\b 0.0b 0.\f\f 0.001 0.06 0.11 1.31 0.062 No 1.001.00 COR = crude odds ratio; CI = con5dence interval; AOR = adjusted odds ratio. Children were reviewed for presence of any coexisting medical and mental-psychiatric comorbid conditions. Chil- dren with cerebral palsy were twenty-one-fold more likely to have severe-profound intellectual disability compared to others without it. 9is result is supported by early 5ndings which also observed an increased risk of intellectual disability in children with cerebral palsy [20]. 9ere was no statistical signi5cant relationship found between severity of intellectual disability and other comorbid conditions. 5. Conclusions Severity of intellectual disability is positively and signi5- cantly associated with environmental factors. Perinatal and postnatal insults including labor complications and being admitted to neonatal intensive care unit during neonatal period were signi5cantly associated with increased risk of severe/profound intellectual disability. Children with cerebral palsy were at a more risk of having severe/profound intellec- tual disability than those without it. 6. Study Limitations Being a hospital-based, descriptive cross-sectional study, this study included only study participants attending KNH; therefore 5ndings may not re ect actual factors from general population in the country, and so results might not be generalizable. Because of the nature of study design, being a cross-sectional study, it limits its utility for causal inference.

Conflicts of Interest 9e authors declare that there are no con icts of interest regarding the publication of this article. Neurology Research International11 Acknowledgments 9e authors acknowledge valuable contributions provided by Mr. Michael Habtu in statistical analysis. Special thanks are due to the Kenyatta National Hospital administration for providing permission to conduct this study and stal from mental and pediatric departments and Dr. Josephine Omondi for their cooperation and assistance in collecting data.

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[20] B.W.Camp,S.H.Broman,P.L.Nichols,andM.Lel,“Maternal and neonatal risk factors for mental retardation: de5ning the ‘at- risk’ child,” Early Human Development ,vol.\f0,no.2,pp.1\f6– 173, 166\b. Stem Cells International Hindawi www.hindawi.com Volume 2018 Hindawi www.hindawi.comVolume 2018 M E D I AT O R S I N F L A M M AT I O N of Endocrinology International Journal of Hindawi www.hindawi.com Volume 2018 Hindawi www.hindawi.com Volume 2018Disease Markers Hindawi www.hindawi.comVolume 2018 BioMed Research International Oncology Journal of Hindawi www.hindawi.com Volume 2013 Hindawi www.hindawi.comVolume 2018 Oxidative Medicine and Cellular Longevity Hindawi www.hindawi.com Volume 2018PPAR Research Hindawi Publishing Corporation http://www.hindawi.com Volume 2013Hindawi www.hindawi.com The Scienti pc World Journal Volume 2018 Immunology ResearchHindawi www.hindawi.com Volume 2018 Journal of Obesity Journal of Hindawi www.hindawi.comVolume 2018 Hindawi www.hindawi.comVolume 2018 Computational and Mathematical Methods in Medicine Hindawi www.hindawi.com Volume 2018 Behavioural Neurology Ophthalmology Journal of Hindawi www.hindawi.comVolume 2018 Diabetes Research Journal of Hindawi www.hindawi.comVolume 2018 Hindawi www.hindawi.comVolume 2018Research and TreatmentAIDS Hindawi www.hindawi.comVolume 2018 Gastroenterology Research and Practice Hindawi www.hindawi.com Volume 2018 Parkinson’s Disease Evidence-Based Complementary and Alternative Medicine Volume 2018 Hindawi www.hindawi.com Submit your manuscripts at www.hindawi.com Copyright ofNeurology ResearchInternational isthe property ofHindawi Limitedandits content maynotbecopied oremailed tomultiple sitesorposted toalistserv without the copyright holder'sexpresswrittenpermission. However,usersmayprint, download, oremail articles forindividual use.