DSM5智力障礙診斷實(shí)用實(shí)用標(biāo)準(zhǔn)及原文

1、標(biāo)準(zhǔn)實(shí)用文案診斷標(biāo)準(zhǔn)：智力障礙（智力發(fā)育障礙）是起病于發(fā)育時(shí)期，在概念、社交和實(shí)用領(lǐng)域中的智力和適應(yīng)功能的缺陷。須符合以下三個(gè)診斷標(biāo)準(zhǔn)：A經(jīng)臨床評估和個(gè)體化、標(biāo)準(zhǔn)化的智力評測確認(rèn)的智力功能障礙，如推理、問題解決、計(jì)劃、抽象思維、判斷、學(xué)業(yè)學(xué)習(xí)和基于經(jīng) 驗(yàn)的學(xué)習(xí)。B適應(yīng)功能缺陷造成未能達(dá)到發(fā)育及社會(huì)文化相稱的個(gè)人獨(dú)立性及社會(huì)責(zé)任標(biāo)準(zhǔn)。在沒有持續(xù)幫助的情況下，該適應(yīng)功能缺陷限制 了其在多個(gè)環(huán)境中，如家庭、學(xué)校、工作和社區(qū)，的一個(gè)或多個(gè)日常生活功能，如交流、社會(huì)參與和獨(dú)立生活。C智力和適應(yīng)缺陷起病于發(fā)育時(shí)期。嚴(yán)重程度則基于ICD-10-CM 編碼如下:嚴(yán)重度概念領(lǐng)域社交領(lǐng)域?qū)嵱妙I(lǐng)域文檔輕在學(xué)齡前兒童

2、，可能沒有 明顯的概念區(qū)別。對于學(xué) 齡兒童和成人，存在學(xué)習(xí) 困難，包括讀、寫、計(jì)算、 時(shí)間金錢的概念，在一個(gè) 或多個(gè)領(lǐng)域需要幫助以達(dá) 到年齡預(yù)期的水平。在成 人，則有抽象思維、執(zhí)行 功能（如計(jì)劃、策略、最 優(yōu)設(shè)定及認(rèn)知靈活性）、 短時(shí)記憶以及對學(xué)業(yè)能力的應(yīng)用（如讀、財(cái)務(wù)管理）相較之下，其社交技巧不成熟。比如， 在準(zhǔn)確感知同伴的社交線索方面存在 困難。交流、對話和語言相較于匹配年 齡更為具體化及不成熟。往往能被同伴 注意到其在以年齡相稱的方式控制行 為及情緒方面存在困難。 難以完全體會(huì) 到社交風(fēng)險(xiǎn)，社交判斷不成熟，存在被 他人控制的風(fēng)險(xiǎn)（受騙）。在個(gè)人護(hù)理方面其能力與年齡相稱。但是在復(fù) 雜的日常

3、生活行為上與同齡相較需要幫助。在成人身上，購物、交通、家務(wù)及照顧兒童及 財(cái)務(wù)管理等方面需要幫助。娛樂活動(dòng)的技能則 與同齡人相近，不過在安全相關(guān)及組織方面任 需要幫助。在成人，可勝任不需要抽象思維的 的工作。在作出醫(yī)療衛(wèi)生及法律相關(guān)決策以及 學(xué)習(xí)勝任完成熟練技巧性的工作等方面需要 幫助。在供養(yǎng)家庭方面也是典型的需要幫助。嚴(yán)重度概念領(lǐng)域社交領(lǐng)域?qū)嵱妙I(lǐng)域中雖然有在成長，但是概念技 巧洛后于同齡兒。在學(xué)齡 前兒童，語言能力及入學(xué) 前學(xué)業(yè)技巧發(fā)展緩慢。在 學(xué)齡期兒童，讀、寫、計(jì) 算、理解時(shí)間和金錢方面 進(jìn)展緩慢，并且與同伴相 較明顯受限。在成人，學(xué)業(yè)能力發(fā)展典型 而言僅限于初級水平，在 工作和生活中需要

4、學(xué)業(yè)技在整個(gè)發(fā)育階段，社交及交流行為與同 齡兒相比有顯著不同。通常主要的交流方式是口語，但是與同齡兒相比顯著 的更簡單。發(fā)展關(guān)系顯著與家庭及朋友相關(guān)，但個(gè) 體可能在人生中獲得成功的友情關(guān)系 甚至在成人期獲得浪漫關(guān)系。然而個(gè)體 可能不能準(zhǔn)確的接受或解讀社交線索。社交判斷及決策能力有限，監(jiān)護(hù)人需要 在生活決策提供幫助。與正常個(gè)體發(fā) 展友誼經(jīng)常為交流及社會(huì)能力的局限作為成年人，可以完成諸如進(jìn)食、穿衣、排泄 及衛(wèi)生等個(gè)人需求。雖然需要更多的教育及時(shí) 間才能在這些方面獲得獨(dú)立，并且需要人提 醒。相應(yīng)的，成人期亦可完成在家務(wù)活動(dòng)， 但是同 樣需要額外的教育，并且要完成成人水平的 工作往往需要持續(xù)幫助。個(gè)體

5、作為雇員可以完成需要有限的概念及 交流技巧的工作，但需要同事、上司等的幫 助來應(yīng)對涉及到社會(huì)期望、復(fù)雜性工作及附 帶責(zé)任的如計(jì)劃安排、交通、健康福利及財(cái)巧的地方均需要幫助。完所影響。在需要成功完成的工作上，顯務(wù)管理嚴(yán)重度概念領(lǐng)域社交領(lǐng)域?qū)嵱妙I(lǐng)域重概念化技能的習(xí)得有限。個(gè) 體通常對書面語言及涉及 到數(shù)字、數(shù)量、時(shí)間及金 錢的概念理解有限。在一 身中監(jiān)護(hù)人均需要提供解 決問題的額外幫助。在詞匯及語法方面?zhèn)€體的口語水平有限。話語可能是單獨(dú)的字或詞， 以及可 能通過輔助的方式補(bǔ)充。交流的內(nèi)谷局 限于當(dāng)下的日常生活事件。 語言更多地 用于社會(huì)交流而不是表達(dá)。個(gè)體能夠理 解簡單的演講及手勢交流。同家庭成員

6、個(gè)體在日常生活的所有活動(dòng)均需要幫助，包括進(jìn)食、穿衣、洗澡級排泄。在任何時(shí)間個(gè)體 均需要監(jiān)護(hù)。個(gè)體無法在涉及自己及他人安 全上做出負(fù)責(zé)任的決策。在成人，參與家庭 任務(wù)、娛樂及工作均需要幫助。在所有領(lǐng)域 的技能均需要長期的教學(xué)及不斷的幫助。不顯著概念化技巧往往涉及實(shí)體 世界而非象征性過程。個(gè) 體能夠使用對象通過目標(biāo) 導(dǎo)向的方式完成自我照 顧、工作及娛樂。一些特定的視覺空間技能， 如通過物質(zhì)特性匹配和排 序可能可以習(xí)得。然而， 共患的動(dòng)作及感覺障礙可及熟悉個(gè)體的天糸是快樂及幫助的來個(gè)體對于語言或手勢的象征性交流的理 解十分局限，可能理解一些簡單的指導(dǎo) 或手勢。其表達(dá)自己的需求和感情大多 通過非語言非

7、象征的交流方式。個(gè)體享受同熟悉的家庭成員、監(jiān)護(hù)人、 熟人的關(guān)系，并且通過手勢或情感線索 發(fā)起或回應(yīng)社交互動(dòng)。共患的感覺或軀 體損傷可能影響一些社會(huì)行為。適應(yīng)行為，如自殘，在極少數(shù)群體中有表現(xiàn)。 個(gè)體在身體照顧、健康及安全方面完全依賴于他人，雖然其可能也能夠參與其中一些活動(dòng)。 沒有嚴(yán)重軀體損傷的個(gè)體可以協(xié)助一些家庭 的日常工作，如端菜上桌。使用物體的簡單 活動(dòng)可能是在高度持續(xù)的協(xié)助下參與一些職 業(yè)活動(dòng)的基礎(chǔ)。娛樂活動(dòng)可能涉及，如享受 音樂、看電影、散步、水上活動(dòng)，均需要他 人幫助。共患的軀體及感覺障礙常常是參與 家庭、娛樂及工作活動(dòng)的障礙 （除了觀看）。標(biāo)準(zhǔn)實(shí)用文案說明：嚴(yán)重水平是通過適應(yīng)功能，

8、而非IQ水平來定義，因?yàn)樗鑾椭乃绞怯蛇m應(yīng)功能決定的。此外，在低值 IQ測試的可信度較低。診斷特點(diǎn)：智力障礙的基本特征是全面心智能力的缺陷（診斷標(biāo)準(zhǔn)A），及于個(gè)體在年齡、性別、社會(huì)文化相匹配的對照的日常適應(yīng)功能的障礙（診斷標(biāo)準(zhǔn)B）,起病與發(fā)育時(shí)期（診斷標(biāo)準(zhǔn)C），診斷應(yīng)該基于臨床評估及標(biāo)準(zhǔn)化的智力和適應(yīng)功能評測的結(jié)合。DSM 涉及到的調(diào)整：1、 適應(yīng)功能結(jié)構(gòu)的調(diào)整： DSM 5將DSM IV TR中，適應(yīng)功能涵蓋包括溝通交際、 自我照顧、居家生活、社會(huì)/人際技能、社會(huì)資源運(yùn)用、自我指示、功能性學(xué)科 技能、工作、休閑娛樂、健康和安全等10個(gè)方面，在其中至少兩個(gè)方面存在缺 陷即可認(rèn)為適應(yīng)功能存在

9、缺陷，調(diào)整為概念、社交和實(shí)用三個(gè)領(lǐng)域，并規(guī)定在其 中一個(gè)領(lǐng)域存在缺陷即可診斷為適應(yīng)功能缺陷。2、分類標(biāo)準(zhǔn)的調(diào)整：DSM 5將DSM IV TR中根據(jù)IQ分?jǐn)?shù)對智力障礙進(jìn)行分類調(diào) 整為根據(jù)個(gè)體適應(yīng)功能缺陷的嚴(yán)重程度將智力障礙標(biāo)注為輕度、中度、重度和極重度四種，并列舉出了輕度、中度、重度和極重度患者在概念、社交和實(shí)用領(lǐng)域 的表現(xiàn)。“因?yàn)樗鑾椭乃绞怯蛇m應(yīng)功能決定的。此外，在低值IQ測試的可信度較低?！辈⑶摇翱赡苡绊憸y評分?jǐn)?shù)的因素包括練習(xí)效應(yīng)和“ Flynn效應(yīng)”（即由于過時(shí)的測評常模造成過高分?jǐn)?shù)）?！?“智商測評分?jǐn)?shù)是對概念功能的粗略估 計(jì),不能充分地評估現(xiàn)實(shí)生活情況中的推理能力和對實(shí)用任務(wù)的

10、掌握能力，例如，智商得分70以上的個(gè)體可能在社交判斷、社交理解和適應(yīng)功能的其他領(lǐng)域上有 嚴(yán)重的適應(yīng)性行為問題，以致其實(shí)際功能與智商得分更低的個(gè)體的表現(xiàn)相當(dāng)，因此,在解釋智商測評的結(jié)果時(shí)需要臨床判斷”3、 障礙發(fā)生時(shí)間的調(diào)整： DSM 5將DSM IV TR中診斷標(biāo)準(zhǔn)是障礙發(fā)生在 18歲以 前調(diào)整為發(fā)育時(shí)期。因?yàn)橛捎谥橇φ系K成因的復(fù)雜性，很難嚴(yán)格定義障礙發(fā)生時(shí)間的范圍，故而采取了更為寬泛的表達(dá)。文檔附：DSM 5 原文In tellectual disability (in tellectual developme ntal disorder) is a disorder with on set

11、duringthe developmental period that includesbothintellectualand adaptivefun cti oningdeficits in con ceptual, social, and practical doma ins. The follow ingthree criteria must be met:A. Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract thinking, judgment, aca

12、demic learning, and learning from experienee, con firmed by both cli ni cal assessme nt and in dividualized, sta ndardizedin tellige nee testi ng.B. Deficits in adaptive functioning that result in failure to meet developmental andsocio- cultural standards for personal independence and social respons

13、ibility. Without on go-ing support, the adaptive deficits limit fun cti oning in one ormore activities of daily life, such as commu ni cati on, social participati on, andin depe ndent liv ing, across multipleen viro nmen ts, such as home, school, work,and commu ni ty.C. On set of in tellectual and a

14、daptive deficits duri ng the developme ntal period.Note: The diag no stic term in tellectual disability is the equivale nt term for the ICD-11 diag-no sisof in tellectualdevelopme ntal disorders. Although the termintellectual disabilityis used throughout this manual, both terms are used in thetitle

15、to clarify relati on ships with other classificati on systems. Moreover, a federal statute in the United States (Public Law 111-256, Rosa s Law) replaces the term mental retardationwith intellectual disability, and research journals use the termin te/ecfua/disability. Thus, in tellectual disability

16、is the term in com mon use bymedical, educati on al,and other professi ons and by the lay public and advocacygroups.Codi ng note: The ICD-9-CM code forin tellectualdisability(i ntellectualdevelopme ntaldisorder) is 319, which is assig ned regardless of the severity specifier.The ICD-10-CM code depen

17、ds on the severity specifier (see below).Specify current severity (see Table 1):(F70) Mild(F71) Moderate(F72) Severe (F73)Profou ndSpecifiersThe various levels of severity are defined on the basis of adaptive functioning, and not IQ scores, because it is adaptivefunctioningthat determinesthe level o

18、fsupports required. Moreover, IQ measures are less valid in the lower end of the IQ ran ge.Diag no stic FeaturesThe esse ntial features of i ntellectual disability (in tellectual developme ntal disorder)are deficits in general mental abilities (Criterion A) and impairment in everyday adaptivefun cti

19、 oning,in comparis onto an in dividual s age-, gen der-, andsocioculturallymatched peers (Criteri on B). On set is duri ng the developme ntalperiod (Criteri on C). The diag no sisof in tellectual disability is based on both cli ni calassessme nt and sta ndardized testi ng of in tellectual and adapti

20、ve fun cti ons.標(biāo)準(zhǔn)實(shí)用文案TABLE 1 Severity levels for in tellectualdisability (in tellectualdevelopme ntaldisorder)Severity evelCon ceptual doma inSocial doma inPractical domai nMildFor preschool childre n, there may be no obvious con ceptual differe nces. For school-age childre n and adults, there are d

21、ifficulties in lear ning academic skills in volvi ng readi ng, writi ng, arithmetic, time,ormon ey, with supportn eededn one or more areas to meet age-related expectati ons. In adults, abstract thi nking, execu tive fun cti on (i.e., pla nning, strategiz ing, prioritysett ing,and cog nitive flexibil

22、ity), and short-term memory, as well as functional use ofacademicskills (e.g., read ing,moneyban ageme nt), areimpaired.Compared with typically develop ing agemates, the in dividual is immature in social n teracti ons. For example, there maybediffi- culty in accurately perceiving peerssocial cues. C

23、ommunication, conversation, and lan- guage are more concrete or mmature tha n expected for age. There may be difficulties reg-ulat ing emoti on andbehavior in age-appropri-ate fashi on; thesedifficulties are no ticed bypeers in socialsituati ons. There is limitedun dersta ndingof risk in social situ

24、ati ons;social judgme nts immature for age, and the person is at risk of being mani pulated by others (gullibility).The in dividual may fun cti on age-appropriately in pers onal care. In dividuals n eed somesupportwith complex daily living tasks in comparison to peers. In adulthood, supports typical

25、ly involve grocery shop- ping, tran sportati on, homeandchild-care orga nic-ing, n utritious foodpreparati on, and banking andmoneyman ageme nt. Recreati onal skills resemblethoseof age-mates, although judgme nt related to well-be ing and orga ni zati on arou ndrecreati onrequires support .In adulth

26、ood, competitive employment isoften seen in jobs that do notempha- size conceptual skills. Individuals gen erally n eedsupport to make health caredecisions and legaldecisions, and to learn toperform a skilled vocationcompetently. Supportis typically n eeded to raise afamily.TABLE 1 Severity levels f

27、or in tellectualdisability(in tellectualdevelopme ntaldisorder) con ti nuedSeveritylevelCon ceptual domai nSocial doma inPractical doma inModerateAll through developme nt, the in dividual s con ceptual skills lag markedly behind those of peers. For preschoolers, lan- guage and pre-academic skills de

28、velop slowly. For school-age childre n, progress in read ing, writing, mathematics, and un dersta nding of time and money occurs slowly across the school years and is markedly limited comparedwiththat of peers. For adults, academic skill developme nt is typically at an eleme ntary level, and support

29、 is required for all use of academic skills in work and pers onal life. On go-The in dividual shows marked differe nces from peers in social andcommunicativebehavior across development. Spoken lan guage is typi- cally a primary tool for social commu ni cati onbut is much lesscomplex tha n that of pe

30、ers.Capacity forrelati on ships isevide nt in ties to family andfrien ds, and the in dividual mayhavesuccessful frie ndships across life and sometimes romantic relations in adulthood. However, in dividuals may not perceive or in terpret social cues accurately. Social judg- ment and decision-making a

31、bilities are lim- ited, and caretakers must assist the pers onwith life decisi ons.Frie ndships with typicallydevelop ing peersare ofte n affected by com-muni cati on orsocial limitati ons. Sign ifica ntsocial andcommunicative support isneeded in workThe in dividual can care for pers onal n eeds in

32、volv ing eati ng, dress ing, elim in ati on, and hygiene as an adult, although an extended period of teaching and time is needed for the in dividual to become in depe n-dent in these areas,and remi nders may be n eeded.Similarly,participati on in all household tasks canbeachieved by adulthood, altho

33、ugh anexte ndedperiod of teaching is needed, and ongoing supports will typically occur for adult-level performa nee.Independent employment in jobs that require lim- ited conceptual and communication skills can be achieved, but considerable support from co-work- ers, supervisors, and others is n eede

34、d to man age social expectati on s, job complexities, and ancillary responsibilities such as scheduling, tra nsportati on, health ben efits, and money man ageme nt. A varietyof recreati onal skills caning assista nee on a daily basissett ings for success.be developed. These typi- cally requireSeveri

35、ty levelConceptual domainSocial domain.Practical domainSevereAtta inment of con ceptual skills is limited. The in dividual generally has little un dersta nding of writte n lan guage or ofconcepts in volv ingn umbers,quantity, time, and money. Caretakers provide extensive supports for problem solv in

36、g throughout life.Spoken language is quite limited in terms of vocabulary and grammar. Speech may be sin- gle words or phrases and may be supple- men ted through augme ntative means. Speech and communication are focused on the hereand now withi neveryday eve nts. Lan guage is used for social commu n

37、i cati on more tha n forexplicati on.In dividuals un dersta nd simplespeech andThe in dividual requires support for all activities of daily liv ing, in cludi ng meals, dress ing, bath ing, and elim in ati on. The in dividual requires supervisi on at all times. The in dividual cannot make resp on sib

38、ledecisi ons regard ingwell-be ing of self or others. Inadulthood,participationin tasks at home, recre- ation, andwork requires ongoing support and assis-tan ce.Skill acquisition in all domains involves long- termProfou ndCon ceptual skillsgen erallyin volve the physical world rather tha n symbolic processes. The in dividual may use objects in goal-directed fashion for self-care, work, and recre- ati on. Certain visuospatial skills, such as matchi ng andsort ing basedon physical char- acteristics, may be acquired.However, co-occurri ng motor and sensory impairme