Perspectives of intellectual disability in Asia: epidemiology,

policy, and services for children and adults

Lohsnah Jeevanandam
Movement for the Intellectually Disabled of Singapore, Purpose of review
Singapore, Singapore
Given the scarcity of Asian literature on intellectual disability, the aim of this review
Correspondence to Lohsnah Jeevanandam, DPsych article is to shed light on the epidemiology, policy, and services for children and adults
Clin, Senior Psychologist, Movement for the
Intellectually Disabled of Singapore, 29 Rosyth Road, with intellectual disability in Asia.
Singapore 149310, Singapore Recent findings
Tel: +65 6282 4852; e-mail: lohsnah.hq@minds.org.sg
The prevalence of intellectual disability across Asia appears to be consistent with
Current Opinion in Psychiatry 2009, 22:462–468 western estimates at 0.06–1.3%, with the exception being China at 6.68%. In the only
two studies of m_ntal health conducted in Asia, the prevalence ranged from 4.4 to
48.3%. Some of the common physical health problems among Singaporean adults with
intellectual disability are obesity, high blood pressure, and high blood cholesterol. All
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Asian countries/territories have at least one law or policy that promotes the well being of
persons with disabilities, with Japan being the only country that has a law specifically
enacted for persons with intellectual disability. Although there is an array of services
being offered for children and adults with intellectual disability across south-east Asia,
there is also a variation in the proportion of countries that offer these services.
Summary
Overall, the challenge for Asia will be to develop a localized base of knowledge by
conducting epidemiological studies, modeling after evidence-based practices, and
evaluating its effectiveness. By adopting a scientific approach and formal publication of
data, intellectual disability standards can be evaluated, managed, and improved in a
systematic manner.

Keywords
Asia, epidemiology, intellectual disability, policies, services

Curr Opin Psychiatry 22:462–468

ß 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
0951-7367

be used to refer to countries/territories, such as Taiwan and

Introduction Hong Kong SAR.
Asia is the largest continent in the world, both in area and
population, with almost 4 billion people or the equiva-
lent of 60% of the world’s population (World Health Epidemiology
Organization). Despite this vastness in size and popu- Most of the information available on epidemiology was
lation, there is a dearth of literature on intellectual dis- prevalent rates and sporadic studies regarding causes and
ability in Asia [1,2]. This lack of reliable references has comorbidity of intellectual disability.
compelled many to depend on western literature. Hence,
this review is the first of its kind to focus on Asia, specifi- Terminology and definition of intellectual disability
cally, epidemiology, policies, and services for children and According to the World Health Organization [3], in
adults with intellectual disability. Given the paucity of south-east Asia, the terms and definitions used to com-
literature based in Asia, there was a need to go beyond monly refer to intellectual disability include mental
the review period to 2004, which includes both published retardation, mental handicap, learning disabilities, men-
data and online content. For prevalence estimates only, tal deficiency, and mental subnormality. Additionally, the
data from 1998 onward were included. Geographically, commonly used diagnostic or classification systems of
Asia spans as far north as the Russian Federation and intellectual disability are the AAMR or AAIDD and
toward western Asia and Middle East. For the purpose ICD-10 criteria, followed by the DSM-IV.
of this review, the focus will be on eastern Asia,
south-central Asia, and south-east Asia. Where limited Prevalence
information is not obtained on a certain country, it will Table 1 displays the general population of persons
be excluded from this review. The expression, states, will with intellectual disability (PWID) in Asian states
0951-7367 ß 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI:10.1097/YCO.0b013e32832ec056

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Table 1 General population and official number of persons with intellectual disability in Asian countries/territories
<18 years >18 years Men Women
Country/territory Ya Total population Total PWID Percentage Year (% of total PWID) (% of total PWID) (% of total PWID) (% of total PWID)

China [4] L-M 1 309 480 000 5 540 000 6.68 2006 954 000 (17.22)b – (1.01) <6 years (0.84) <6 years
Hong Kong [5] H 6 916 000 67 000–87 000 1.0–1.3 2008 – – – –
India [6] L-M 1 027 000 000 994 700 0.097 2002 – – 625 800 (62.91) 368 900 (37.09)
Indonesia [7] L-M 201 241 999 384 818 0.19 2000 – – – –
Japan [8] H 127 770 000 547 000 0.43 2005 117 300 (28.00)c 289 600 (69.12)c – –
South Korea [2] H 47 817 000 121 453 0.25 2008 – – – –
Malaysia U-M 26 114 000 – – 2008 – – – –
Mongolia L-M 2 395 830 20 900 0.87 2001 – – – –
(http://apcdproject.org/
countryprofile)
Nepal L 22 736 934 13 171 0.06 2001 – – 6 479 (49.19) 6 692 (50.81)
(http://apcdproject.org/
countryprofile)
Pakistan [9] L 132 352 000 461 038 0.35 1998 – – 254 532 (55.21) 206 506 (44.79)
Philippines L-M 76 504 077 66 113 0.09 2000 – – 35 194 (53.23) 30 919 (46.77)
(http://apcdproject.org/
countryprofile)
Singapore H 4 382 000 – – 2008 – – – –
Sri Lanka L-M 19 207 000 – – 2008 – – – –
Taiwan [10] H 22 958 360 91 004 0.396 2007 22 797 (25.05) 68 207 (74.95) 52 608 (57.81) 38 396 (42.19)
Thailand [11] L-M 60 700 000 28 524 0.05 2000 – – – –
Where prevalence figures are obtained, the total population indicated is at the point of data collection. Where prevalence figures are not obtained, the total population is referenced from World Health
Statistics (2008), World Health Organization. PWID, persons with intellectual disability.
a
Economy as defined by The World Bank Income Category: L (low income), L-M (lower-middle income), U-M (Upper-middle), H (high income).
b
Estimated number of children under 6 years of age with intellectual disability.
c
Based on a total population of 419 000 persons with intellectual disability.
Perspectives of intellectual disability in Asia Jeevanandam
463

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 464 Mental retardation and developmental disorders

[2,4,5–9,10,11]. The prevalence of only intellectual ture birth (8.57%), and intrauterine asphyxia (6.43%). In
disability or mental retardation was included. Prevalence another earlier Chinese study of cause [22], the detailed
figures available for other categorizations such as ‘men- medical and developmental histories of 79 children,
tally impaired’ (Malaysia) (Asia-Pacific Development 2–6 years of age were explored. The most common cause
Center on Disability, http://apcdproject.org/countrypro of intellectual disability was identified to be prenatal
file, a website that provides general information, statisti- factors (62.5%), followed by postnatal reasons (21.4%),
cal data on disability profile, current situation of persons and perinatal reasons (16.1%). In Pakistan, Yaqoob et al.
with disabilities, update on the country’s participation in [23] examined the causes of intellectual disability among
the Asian and Pacific Decade of Disabled Persons 2003– 40 children (6–10 years of age) with mild intellectual
2012, and profile of disability-related organizations in the disability. For 50% of the cases, the cause could not be
various Asian countries) or ‘mentals’ (Sri Lanka) (http:// identified, whereas 28% of the cases were attributed to
apcdproject.org/countryprofile) were excluded owing to postnatal reasons, such as social deprivation and malnu-
the ambiguity of these expressions. As for Singapore, trition. A further 22% of cases were caused by prenatal
while the prevalence was not obtainable, the number of factors.
users of programmers for persons with disabilities has
been documented on a yearly basis (MCYS) [12]. Comorbidity
Intellectual disability has high comorbidity with issues
Overall, the prevalence of PWID ranged from 0.06% in related to mental health [24], physical health [24], and
Nepal to 6.68% in China. This range is vast and encap- other disorders [25].
sulates the range of western estimates, such as 0.30–
0.40% in Australia [13], 0.70% in Finland [14], and the Mental health problems
Netherlands [15], respectively, and about 0.25% who are It is now increasingly accepted that the prevalence of
known to services in Europe, while the actual prevalence mental health problems in PWID is higher than that
of persons with intellectual and adaptive disabilities may among the general population at a rate of about 60%
be 1.0% [16]. With the exception of China, the other [26] for children and 30–50% for adults [27]. In the only
Asian states displayed a prevalence of less than 1.3%, published study of mental health issues among PWID in
which is comparative with western studies. Although this Asia, Kishore et al. [28] studied the rate and nature of dual
may be suggestive of a genuinely higher prevalence of diagnoses in relation to the severity of intellectual dis-
PWID in China, caution needs to be exercised in the ability in 60 Indian PWID, 12–55 years of age. Mental
interpretation of data that are 10 years apart. Further- status examination and the Reiss Screen for Maladaptive
more, 6.68% is an estimated prevalence based on a Behaviours (RSMB) [29] were conducted for each indi-
sampling survey in which 10 844 persons were found to vidual. Results revealed that 48.3% as measured by the
present with intellectual disability. Given the notable RSMB and 60% as assessed by the clinical interview
relationship between poverty and intellectual disability demonstrated a clinical diagnosis. The most common
[17], the low prevalence rates in low-income countries, diagnosis was unspecified psychosis, followed by affective
such as Nepal (0.06%) and Pakistan (0.09%) is surprising. disorders. The mild intellectual disability group presented
Furthermore, given the widespread stigma [18,19] and with more affective disorders, whereas the moderate intel-
discrimination [17,20] associated with persons with dis- lectual disability group with more psychosis.
ability and their families in Asian cultures, underreport-
ing is highly possible. In a study presented at IASSID Conference [30] by the
current author, 1007 adults with moderate intellectual
In the six states that have reported sex prevalence, that is, disability in Singapore attending sheltered workshops
India, Nepal, Pakistan, Philippines, Taiwan, and China and training and development centers were administered
(less than 6-year-olds), there is consistently a higher the Developmental Behaviour Checklist-Adult version
prevalence of intellectual disability among men than [31]. Results yielded a 4.4% prevalence, with the most
among women, as found with other studies [14]. Only common presentation being disruptive behaviors, fol-
Nepal demonstrated an almost equal sex prevalence rate. lowed by communication disturbance and self-absorbed
behaviors. One plausible reason for the significant differ-
Causes of intellectual disability ence in prevalence rate of mental health issues across
Lin et al. [21] studied the Taiwan disability registers and these two studies is that the study by Kishore et al.
found the most common causes of intellectual disability focused on a clinical sample that was known to display
to be congenital disease (47.72%), followed by diseases behavioral problems for 2 months and hence mental
(31.67%), and other reasons (17.37%). In a sampling health issues are likely to be overrepresented in this
survey conducted in China on 0–6-year-olds [4], the sample. Overall, any conclusion about the nature and
most common cause of intellectual disability was prevalence of mental health issues in Asian samples are
unknown (29.29%), asphyxia at birth (12.50%), prema- reserved until more comparable studies are explored

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Perspectives of intellectual disability in Asia Jeevanandam 465

across various ages, severity of intellectual disability, and [35] appears to provide the PWID and the family with
the use of similar modes of diagnosis. several and possibly the most opportunities for income
security. Some of the opportunities provided are the
Physical health problems Pension Scheme for Disabled Persons that enables
In Singapore, the current author explored the physical PWID to yearly pensions (e.g., $10 510 for profound or
health status of 817 adults with moderate intellectual severe intellectual disability), Special Child Rearing
disability through a health screening exercise conducted Allowance for caregiver of children under 20 years of
by a medical agency. Results revealed that the most age at $360 per month, Insurance System for Mentally
common physical health problems were obesity and Physically Disabled Dependants for individuals less
(42.1%), high blood pressure (24.2%), and high blood than 35 years of age, a public national health and pension
cholesterol (16%). insurance that entitles the person a subsidy of up to 70%
of treatment cost, and finally tax deductions.
General comorbidity
In Hong Kong, Tang et al. [25] studied the profile of 488 Appreciating the need for long-term financial planning
children under 6 years of age with intellectual disability and guardianship after caregivers pass on, two countries
who had been referred for complaints of development, were found to offer such schemes, the Special Needs
emotional, and behavior problems. The most common Trust Company in Singapore that has been recently
comorbidity was Autism Spectrum Disorder (32.8%), set-up [36] and the National Trust for welfare of persons
followed by discrepant language delay (17.2%) and dis- with Autism, Cerebral Palsy, Mental Retardation, and
crepant dross motor delay (7.6%). Multiple Disabilities Act in India [37].

Policies for children and adults Most Asian states such as China, India, Hong Kong,
All the Asian states have at least one law or policy that Japan, South Korea, Pakistan, Philippines, Singapore,
promotes the well being of persons with disabilities, with Sri Lanka, Taiwan, and Thailand offer employment
Japan [32] being the only Asian country that has a law schemes for PWID. The most common are the quota
specifically enacted for PWID (Table 2) [33,34]. scheme, levy and grant scheme, or a combination of both.
In Singapore [38], the Open Door Fund was set up in
According to WHO, in south-east Asia, there are several 2006 and provides financial assistance to employers of
forms of government benefits made possible for adults persons with disabilities. Companies can seek funding up
with intellectual disability or the family of a child with to 30–90% of the cost for projects such as workplace
intellectual disability, such as direct payment of money modification and training program. In Japan [35], under
for a specific course (80% of the countries), disability Law for the Employment Promotion of Persons with
pension (60%), subsidies for food, housing, medication, or Disabilities, any company with more than 56 full-time
transportation (60%), health security (40%), fiscal or tax employees is subject to an employment obligation system
benefits (40%), and social security (20%). Based on the to employ persons with intellectual or physical disability.
relatively little information that could be gathered, Japan The companies will be paid $275 per person per month

Table 2 Policy or law enacted specifically for or related to persons with intellectual disability
Country/territory collaboration Disability policy or law Year enacted International/regional

China The law of the People’s Republic of China on the protection 1990 þa,b
of Disabled Persons
Hong Kong SAR Disability Discrimination Ordinance 1996 þa,c
India Persons with Disabilities (Equal Opportunities, Protection 1995 þa,b
of Rights and Full Participation)
Indonesia Act of the Republic of Indonesia, Law 4 1997 þa,b
Japan Law for the Welfare of Intellectually Disabled Personsd 1960 þa,b
South Korea Welfare Development for Persons with Disabilities 1998 þa,b
Malaysia Disability Welfare Act 2001 þa,b
Mongolia Mongolian Social Security Law for People with Disabilities 1995 þa,b
Nepal The Protection and Welfare of the Disabled Persons Act 2039 1982 þa,b
Pakistan Disabled Persons Employment and Rehabilitation Ordinance 1981 þa,b
Philippines Magna Carta for Disabled Persons Republic Act 7277 1995 þa,b
Singapore Mental Capacity Act 2008 þa
Sri Lanka Protection of the Rights of Persons with Disabilities Act, No. 28 1996 þa,b
Taiwan Taiwan Protection Law for the Physically Mentally Disabled 1997 þa,c
Thailand Rehabilitation of Disabled Persons Act 1991 þa,b
AFID, Asian Federation on Intellectual Disabilities.
a
Participating member of the UNESCAP Biwako Millennium Framework, Asian and Pacific Decade of Disabled Persons, 2003–2012 [33].
b
Signatory to the UN Convention Rights of Persons with Disabilities [34].
c
Obliged to comply with the UN Convention Rights of Persons with Disabilities with China being a signatory.
d
Policy or law specific for persons with intellectual disability.

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 466 Mental retardation and developmental disorders

for every person by which they exceed the quota, or and rights-based society. Furthermore, most of the Asian
would have to in turn pay $500 per person per month for states have signed the UN Convention on the Rights of
not meeting the quota. The employment of PWID in Persons with Disabilities [34]. Individual countries are
Japan by special subsidiary companies as of 1 June 2008 also on their own quest to further promote the rights of
was 3080 persons [35]. In Korea, 22.5% (309 of 1211) of PWID, such as Singapore having dedicated 2006 to
high school graduates were employed in 2005 [39]. In Disability Awareness Public Education program [41]
contrast, the employment of PWID in other countries and in Pakistan the National Policy and Work Plan for
such as Philippines appears scarce [40]. disabilities in 2006 [42]. Appreciating the need for
research development, the Asian Federation on Intellec-
International/regional collaboration to promote the tual Disabilities (AFID) (http://www.afid73.org) consist-
well being of persons with intellectual disability ing of 15 Asian member states, organizes conferences
A lot of polices and laws enacted that are related to PWID once every 2 years in an Asian country to provide a
are a result of the states’ participation and commitment to platform for the exchange of ideas. Overall, the participa-
international and regional projects, as summarized in tion in such projects regionally and internationally is a
Table 2. One such notable and influential project in this strong indicator of Asia’s fervent commitment to promote
region is the adoption of the Asian and Pacific Decade of the well being of PWID.
Disabled Persons, 1993–2002, which is supported by the
United Nations Economic and Social Commission for
Asia and the Pacific (UNESCAP) [33]. This project was Services for children and adults
later extended for another decade, 2003–2012 and in line Table 3 summarizes the range of services available
with the decade’s theme is the Biwako Millennium for children and adults with intellectual disability in
Framework for action toward an inclusive, barrier-free south-east Asian countries only, as defined by WHO

Table 3 Range of services available for children and adults with intellectual disability in WHO defined south-east Asian countries only
Type of service Children and adolescents (% of south-east Asian countries) Adults

Intellectual disability services

Screening, assessment, or orientation 80 60
Early intervention 100 –
Individual support or case management 80 75
Specialized psychological or psychiatric intervention 75 50
Psycho-social rehabilitation 80 80
Day center or hospital 80 80
Educational opportunities
Special schools 100 –
Special class in regular or integrated class 80 –
Support in regular class 60 –
Homebound services 80 –
Preschool or kindergarten 100 –
Literacy program – 75
Adult enhancement program – 50
Professional training – 80
Occupational, vocational, or work settings
Sheltered employment – 60
Work stations – 60
Supported employment – 60
General work skills, training, or development – 80
Residential services
Support to independent living 60 60
Foster homes 25 20
Group homes 60 60
Nursing homes 0 20
Asylum-type institutions 25 25
Other types of services
Leisure activities 60 25
Transportation 0 0
Assistive technology 40 40
Rights or advocacy support 80 60
Supply of meal or food 80 60
Health services
Inpatient health services 60 40
Primary healthcare 100 80
Specialized health services 80 50
Physical rehabilitation 80 80
–, not applicable. Data from World Health Organization. Atlas Global Resources for Persons with Intellectual Disabilities (2007).

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Perspectives of intellectual disability in Asia Jeevanandam 467

Table 4 Range of services available for persons with intellectual disability by country/territory
Early Special Integrated Day/independent Vocational Group
Country/territory intervention schools education living centers Sheltered centers Hostels homes

China þ þ þ þ þ þ
Hong Kong SAR þ þ þ þ þ þ þ
India þ þ þ þ þ þ  
Indonesia þ þ þ þ  
Japan þ þ þ þ þ þ þ þ
South Korea þ þ þ þ þ þ  þ
Malaysia þ þ þ þ þ  
Mongolia
Nepal þ þ
Pakistan þ þ  
Philippines þ þ þ þ þ  
Singapore þ þ þ þ þ þ þ þ
Sri Lanka þ þ
Taiwan þ þ þ þ þ þ þ
Thailand þ þ þ þ þ
þ, presence of the service; , absence of the service, and blank indicates that relevant information could not be found.

[3]. On the whole, the countries that responded to the region and differences will continue to prevail. The
WHO survey provided an array of services. All the challenge for Asia will then be to galvanize and orches-
countries provided rehabilitative services such as early trate its resources to create a localized base of knowledge
intervention, special schools, and in contrast, the minority by conducting epidemiological studies, modeling after
of countries providing the less acceptable services such as evidence-based practices, and evaluating the effective-
nursing homes and asylum-type institutions. Only a ness, and essentially, engaging in rigorous research and
selected number of these services were identified and formal publication of data.
a further inspection by state was explored and is sum-
marized in Table 4.
Acknowledgements
I would like to thank Chiyoko Numata (Japan) and Pramila Balasun-
A noteworthy study to be mentioned is the comprehen- daram (India) for assisting to provide information from their countries.
sive study of mental healthcare for adults with intellec- Kusidiyanti W. Intellectual Disabilities Country Report. The Group
tual disability in Asia by Kwok and Chui [2]. They found Training Course on Intellectual Disabilities, 2003. http://www.gtid.net/
countryreport/2003-CountryReport(Indonesia2).pdf. Ratnawathi DKD.
that the type and range of mental health services across Country Report of Sri Lanka. Prepared for The 25th Asia-Pacific
Asia varied widely. Of the countries that were surveyed, Intranational Seminar on Special Education, 2005. http://www.nise.
Hong Kong, South Korea, and China were found to go.jp/kenshuka/josa/kankobutsu/pub_d/d-240/d-240_07.pdf.
provide psychiatric services for children, adult-inpatient,
adult-outpatient, adult-day hospital, and adult-outreach
services. Hong Kong [43] also pioneered the setting up of References and recommended reading
Papers of particular interest, published within the annual period of review, have
a Specialist unit called the Psychiatric Unit for Learning been highlighted as:
 of special interest
Difficulties in 1996.  of outstanding interest
Additional references related to this topic can also be found in the Current
World Literature section in this issue (p. 515).

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