DSM 5智力障礙診斷標(biāo)準(zhǔn)及原文

1、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(píng)估和個(gè)體化、標(biāo)準(zhǔn)化的智力評(píng)測(cè)確認(rèn)的智力功能障礙，如推理、問(wèn)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(méi)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)域輕在學(xué)齡前兒童，可能沒(méi)有明顯的

2、概念區(qū)別。對(duì)于學(xué)齡兒童和成人，存在學(xué)習(xí)困難，包括讀、寫(xiě)、計(jì)算、時(shí)間金錢(qián)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(duì)學(xué)業(yè)能力的應(yīng)用（如讀、財(cái)務(wù)管理）的受損。對(duì)于問(wèn)題及解決方案相較于同齡人更顯得具體化。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(duì)話和語(yǔ)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)雜的日常生

3、活行為上與同齡相較需要幫助。在成人身上，購(gòu)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(lè)活動(dòng)的技能則與同齡人相近，不過(guò)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(zhǎng)，但是概念技巧落后于同齡兒。在學(xué)齡前兒童，語(yǔ)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(xiě)、計(jì)算、理解時(shí)間和金錢(qián)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(jí)水平，在工作和生活中需要學(xué)業(yè)技巧的地方均需要幫助。完成日

4、常生活中概念性任務(wù)時(shí)需要持續(xù)的幫助，甚至需要他人完全接管。 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(yǔ)，但是與同齡兒相比顯著的更簡(jiǎn)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)能力的局限所影響。在需要成功完成的工作上，顯著的需要社交及交流的幫助。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，

5、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(lái)應(yīng)對(duì)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)務(wù)管理。個(gè)體可發(fā)展出眾多的娛樂(lè)技能。但往往需要額外的幫助及時(shí)間來(lái)教學(xué)。極個(gè)別的存在適應(yīng)性不良行為并導(dǎo)致社會(huì)問(wèn)題。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(duì)書(shū)面語(yǔ)言及涉及到數(shù)字、數(shù)量、時(shí)間及金錢(qián)的概念理解有限。在一身中監(jiān)護(hù)人均需要提供解決問(wèn)題的額外幫助。在詞匯及語(yǔ)法方面?zhèn)€體的口語(yǔ)水平有限。話語(yǔ)可能是單獨(dú)的字或詞，以及可能通過(guò)輔助的方式補(bǔ)

6、充。交流的內(nèi)容局限于當(dāng)下的日常生活事件。語(yǔ)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(jiǎn)單的演講及手勢(shì)交流。同家庭成員及熟悉個(gè)體的關(guān)系是快樂(lè)及幫助的來(lái)源。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(jí)排泄。在任何時(shí)間個(gè)體均需要監(jiān)護(hù)。個(gè)體無(wú)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(lè)及工作均需要幫助。在所有領(lǐng)域的技能均需要長(zhǎng)期的教學(xué)及不斷的幫助。不適應(yīng)行為，如自殘，在極少數(shù)群體中有表現(xiàn)。顯著概念化技巧往往涉及實(shí)體世界而非象征性過(guò)程。個(gè)體能夠使用對(duì)象通過(guò)目標(biāo)導(dǎo)向的方式完成自我照顧、工作及娛樂(lè)。一些特定的視覺(jué)空間技能，如通過(guò)物質(zhì)特性匹配和排序可能可以習(xí)得。然而，共

7、患的動(dòng)作及感覺(jué)障礙可能影響對(duì)物體的功能使用。個(gè)體對(duì)于語(yǔ)言或手勢(shì)的象征性交流的理解十分局限，可能理解一些簡(jiǎn)單的指導(dǎo)或手勢(shì)。其表達(dá)自己的需求和感情大多通過(guò)非語(yǔ)言非象征的交流方式。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(guò)手勢(shì)或情感線索發(fā)起或回應(yīng)社交互動(dòng)。共患的感覺(jué)或軀體損傷可能影響一些社會(huì)行為。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(méi)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(jiǎn)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(lè)活動(dòng)可能涉及，如享受音樂(lè)、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(jué)障

8、礙常常是參與家庭、娛樂(lè)及工作活動(dòng)的障礙（除了觀看）。在極少數(shù)個(gè)體存在不適應(yīng)行為。說(shuō)明：嚴(yán)重水平是通過(guò)適應(yīng)功能，而非IQ水平來(lái)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(cè)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(duì)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(píng)估及標(biāo)準(zhǔn)化的智力和適應(yīng)功能評(píng)測(cè)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

9、學(xué)科技能、工作、休閑娛樂(lè)、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(duì)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)?！耙?yàn)樗鑾椭乃绞怯蛇m應(yīng)功能決定的。此外，在低值IQ測(cè)試的可信度較低?！辈⑶摇翱赡苡绊憸y(cè)評(píng)分?jǐn)?shù)的因素包括練習(xí)效應(yīng)和“Flynn效應(yīng)”(即由于過(guò)時(shí)的測(cè)評(píng)常模造成過(guò)高分?jǐn)?shù)) ?！?/p>

10、“智商測(cè)評(píng)分?jǐn)?shù)是對(duì)概念功能的粗略估計(jì),不能充分地評(píng)估現(xiàn)實(shí)生活情況中的推理能力和對(duì)實(shí)用任務(wù)的掌握能力, 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(wèn)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(cè)評(píng)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)。附：DSM 5 原文Intellectual disability (intellectual development

11、al disorder) is a disorder with onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social, and practical domains. The following three criteria must be met:A. Deficits in intellectual functions, such as reasoning, problem solving, pl

12、anning, abstract thinking, judgment, academic learning, and learning from experience, confirmed by both clinical assessment and individualized, standardized intelligence testing.B. Deficits in adaptive functioning that result in failure to meet developmental and socio- cultural standards for persona

13、l independence and social responsibility. Without ongo- ing support, the adaptive deficits limit functioning in one or more activities of daily life, such as communication, social participation, and independent living, across multiple environments, such as home, school, work, and community.C. Onset

14、of intellectual and adaptive deficits during the developmental period.Note: The diagnostic term intellectual disability is the equivalent term for the ICD-11 diag- nosis of intellectual developmental disorders. Although the term intellectual disability is used throughout this manual, both terms are

15、used in the title to clarify relationships with other classification systems. Moreover, a federal statute in the United States (Public Law 111-256, Rosas Law) replaces the term mental retardation with intellectual disability, and research journals use the term inte/ecfua/ disability. Thus, intellect

16、ual disability is the term in common use by medical, educational, and other professions and by the lay public and advocacy groups.Coding note: The ICD-9-CM code for intellectual disability (intellectual developmental disorder) is 319, which is assigned regardless of the severity specifier. The ICD-1

17、0-CM code depends on the severity specifier (see below).Specify current severity (see Table 1): (F70) Mild(F71) Moderate (F72) Severe (F73) ProfoundSpecifiersThe various levels of severity are defined on the basis of adaptive functioning, and not IQ scores, because it is adaptive functioning that de

18、termines the level of supports required. Moreover, IQ measures are less valid in the lower end of the IQ range.Diagnostic FeaturesThe essential features of intellectual disability (intellectual developmental disorder) are deficits in general mental abilities (Criterion A) and impairment in everyday

19、adaptive functioning, in comparison to an individuals age-, gender-, and socioculturally matched peers (Criterion B). Onset is during the developmental period (Criterion C). The diagnosis of intellectual disability is based on both clinical assessment and standardized testing of intellectual and ada

20、ptive functions.TABLE 1 Severity levels for intellectual disability (intellectual developmental disorder)Severity levelConceptual domainSocial domainPractical domainMildFor preschool children, there may be no obvious conceptual differences. For school-age children and adults, there are difficulties

21、in learning aca- demic skills involving reading, writing, arithmetic, time, or money, with support needed in one or more areas to meet age-related expectations. In adults, abstract thinking, exec- utive function (i.e., planning, strategizing, priority setting, and cognitive flexibility), and short-t

22、erm memory, as well as functional use of academic skills (e.g., reading, money management), are impaired. There is a somewhat concrete approach to problems and solutions compared withage-mates.Compared with typically developing age- mates, the individual is immature in social interactions. For examp

23、le, there may be diffi- culty in accurately perceiving peers social cues. Communication, conversation, and lan- guage are more concrete or immature than expected for age. There may be difficulties reg- ulating emotion and behavior in age-appropri- ate fashion; these difficulties are noticed by peers

24、 in social situations. There is limited understanding of risk in social situations; social judgment is immature for age, andthe person is at risk of being manipulated by others (gullibility).The individual may function age-appropriately in personal care. Individuals need some support with complex da

25、ily living tasks in comparison to peers. In adulthood, supports typically involve grocery shop- ping, transportation, home and child-care organic- ing, nutritious food preparation, and banking and money management. Recreational skills resemble those of age-mates, although judgment related to well-be

26、ing and organization around recreation requires support. In adulthood, competitive employment is often seen in jobs that do not empha- size conceptual skills. Individuals generally need support to make health care decisions and legal decisions, and to learn to perform a skilled vocation competently.

27、 Support is typically needed to raise a family.TABLE 1 Severity levels for intellectual disability (intellectual developmental disorder) continuedSeverity levelConceptual domainSocial domainPractical domainModerateAll through development, the individuals conceptual skills lag markedly behind those o

28、f peers. For preschoolers, lan- guage and pre-academic skills develop slowly. For school-age children, progress in reading, writing, mathematics, and understanding of time and money occurs slowly across the school years and is mark- edly limited compared with that of peers. For adults, aca- demic sk

29、ill development is typically at an elementary level, and support is required for all use of academic skills in work and personal life. Ongo- ing assistance on a daily basis is needed to complete concep- tual tasks of day-to-day life, and others may take over these responsibilities fully for the indi

30、vidual.The individual shows marked differences from peers in social and communicative behavior across development. Spoken language is typi- cally a primary tool for social communication but is much less complex than that of peers. Capacity for relationships is evident in ties to family and friends,

31、and the individual may have successful friendships across life and sometimes romantic relations in adulthood. However, individuals may not perceive or interpret social cues accurately. Social judg- ment and decision-making abilities are lim- ited, and caretakers must assist the person with life deci

32、sions. Friendships with typically developing peers are often affected by com- munication or social limitations. Significant social and communicative support is needed in work settings for success.The individual can care for personal needs involving eating, dressing, elimination, and hygiene as an ad

33、ult, although an extended period of teaching and time is needed for the individual to become indepen- dent in these areas, and reminders may be needed. Similarly, participation in all household tasks can be achieved by adulthood, although an extended period of teaching is needed, and ongoing support

34、s will typically occur for adult-level performance.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 needed to manage social expectations, job complexities, and ancillary r

35、esponsibilities such as scheduling, transportation, health benefits, and money management. A variety of recreational skills can be developed. These typi- cally require additional supports and learning opportunities over an extended period of time.Maladaptive behavior is present in a significant mino

36、rity and causes social problems.TABLE 1 Severity levels for intellectual disability (intellectual developmental disorder) confinzzed)Severity levelConceptual domainSocial domainPractical domainSevereAttainment of conceptual skills is limited. The individual gen- erally has little understanding of wr

37、itten language or of con- cepts involving numbers, quantity, time, and money.Caretakers provide extensive supports for problem solving 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- mented through augmen

38、tative means. Speech and communication are focused on the here and now within everyday events. Language is used for social communication more than for explication. Individuals understand simple speech and gestural communication. Relation- ships with family members and familiar others are a source of

39、 pleasure and help.The individual requires support for all activities of daily living, including meals, dressing, bathing, and elimination. The individual requires supervision at all times. The individual cannot make responsible decisions regarding well-being of self or others. In adulthood, partici

40、pation in tasks at home, recre- ation, and work requires ongoing support and assis- tance. Skill acquisition in all domains involves long- term teaching and ongoing support. Maladaptive behavior, including self-injury, is present in a signif- icant minority.ProfoundConceptual skills generally involv

41、e the physical world rather than symbolic pro- cesses. The individual may use objects in goal-directed fashion for self-care, work, and recre- ation. Certain visuospatial skills, such as matching and sorting based on physical char- acteristics, may be acquired.However, co-occurring motor and sensory impairments may prevent functional use of objects.The individual has very