DSM 5智力障礙診療實(shí)用標(biāo)準(zhǔn)及原文

診療原則：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)功效的缺點(diǎn)。須符合下列三個(gè)診療原則：A經(jīng)臨床評(píng)定和個(gè)體化、原則化的智力評(píng)測(cè)確認(rèn)的智力功效障礙，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)功效缺點(diǎn)造成未能達(dá)成發(fā)育及社會(huì)文化相稱的個(gè)人獨(dú)立性及社會(huì)責(zé)任原則。在沒(méi)有持續(xù)協(xié)助的狀況下，該適應(yīng)功效缺點(diǎn)限制了其在多個(gè)環(huán)境中，如家庭、學(xué)校、工作和社區(qū)，的一種或多個(gè)日常生活功效，如交流、社會(huì)參加和獨(dú)立生活。C智力和適應(yīng)缺點(diǎn)起病于發(fā)育時(shí)期。嚴(yán)重程度則基于ICD-10-CM編碼以下：嚴(yán)重度概念領(lǐng)域社交領(lǐng)域?qū)嵱妙I(lǐng)域輕在學(xué)齡前小朋友，可能沒(méi)有明顯的概念區(qū)別。對(duì)于學(xué)齡小朋友和成人，存在學(xué)習(xí)困難，涉及讀、寫、計(jì)算、時(shí)間金錢的概念，在一種或多個(gè)領(lǐng)域需要協(xié)助以達(dá)成年紀(jì)預(yù)期的水平。在成人，則有抽象思維、執(zhí)行功效（如計(jì)劃、方略、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。例如，在精確感知同伴的社交線索方面存在困難。交流、對(duì)話和語(yǔ)言相較于匹配年紀(jì)更為具體化及不成熟。往往能被同伴注意到其在以年紀(jì)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，存在被別人控制的風(fēng)險(xiǎn)（被騙）。在個(gè)人護(hù)理方面其能力與年紀(jì)相稱。但是在復(fù)雜的日常生活行為上與同齡相較需要協(xié)助。在成人身上，購(gòu)物、交通、家務(wù)及照顧小朋友及財(cái)務(wù)管理等方面需要協(xié)助。娛樂(lè)活動(dòng)的技能則與同齡人相近，但是在安全有關(guān)及組織方面任需要協(xié)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)生及法律有關(guān)決策以及學(xué)習(xí)勝任完畢純熟技巧性的工作等方面需要協(xié)助。在供養(yǎng)家庭方面也是典型的需要協(xié)助。嚴(yán)重度概念領(lǐng)域社交領(lǐng)域?qū)嵱妙I(lǐng)域中即使有在成長(zhǎng)，但是概念技巧落后于同齡兒。在學(xué)齡前小朋友，語(yǔ)言能力及入學(xué)前學(xué)業(yè)技巧發(fā)展緩慢。在學(xué)齡期小朋友，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(jí)水平，在工作和生活中需要學(xué)業(yè)技巧的地方均需要協(xié)助。完畢日常生活中概念性任務(wù)時(shí)需要持續(xù)的協(xié)助，甚至需要?jiǎng)e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明顯不同。普通重要的交流方式是口語(yǔ)，但是與同齡兒相比明顯的更簡(jiǎn)樸。發(fā)展關(guān)系明顯與家庭及朋友有關(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)體可能不能精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協(xié)助。與正常個(gè)體發(fā)展友情經(jīng)常為交流及社會(huì)能力的局限所影響。在需要成功完畢的工作上，明顯的需要社交及交流的協(xié)助。作為成年人，能夠完畢諸如進(jìn)食、穿衣、排泄及衛(wèi)生等個(gè)人需求。即使需要更多的教育及時(shí)間才干在這些方面獲得獨(dú)立，并且需要人提示。對(duì)應(yīng)的，成人期亦可完畢在家務(wù)活動(dòng)，但是同樣需要額外的教育，并且要完畢成人水平的工作往往需要持續(xù)協(xié)助。個(gè)體作為雇員能夠完畢需要有限的概念及交流技巧的工作，但需要同事、上司等的協(xié)助來(lái)應(yīng)對(duì)涉及到社會(huì)盼望、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)展出色多的娛樂(lè)技能。但往往需要額外的協(xié)助及時(shí)間來(lái)教學(xué)。極個(gè)別的存在適應(yīng)性不良行為并造成社會(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)體普通對(duì)書面語(yǔ)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(wèn)題的額外協(xié)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)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)交流而不是體現(xiàn)。個(gè)體能夠理解簡(jiǎn)樸的演講及手勢(shì)交流。同家庭組員及熟悉個(gè)體的關(guān)系是愉快及協(xié)助的來(lái)源。個(gè)體在日常生活的全部活動(dòng)均需要協(xié)助，涉及進(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)法在涉及自己及別人安全上做出負(fù)責(zé)任的決策。在成人，參加家庭任務(wù)、娛樂(lè)及工作均需要協(xié)助。在全部領(lǐng)域的技能均需要長(zhǎng)久的教學(xué)及不停的協(xié)助。不適應(yīng)行為，如自殘，在極少數(shù)群體中有體現(xiàn)。明顯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)目的導(dǎo)向的方式完畢自我照顧、工作及娛樂(lè)。某些特定的視覺(jué)空間技能，如通過(guò)物質(zhì)特性匹配和排序可能能夠習(xí)得。然而，共患的動(dòng)作及感覺(jué)障礙可能影響對(duì)物體的功效使用。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，可能理解某些簡(jiǎn)樸的指導(dǎo)或手勢(shì)。其體現(xiàn)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)體享有同熟悉的家庭組員、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某些社會(huì)行為。個(gè)體在身體照顧、健康及安全方面完全依賴于別人，即使其可能也能夠參加其中某些活動(dòng)。沒(méi)有嚴(yán)重軀體損傷的個(gè)體能夠協(xié)助某些家庭的日常工作，如端菜上桌。使用物體的簡(jiǎn)樸活動(dòng)可能是在高度持續(xù)的協(xié)助下參加某些職業(yè)活動(dòng)的基礎(chǔ)。娛樂(lè)活動(dòng)可能涉及，如享有音樂(lè)、看電影、散步、水上活動(dòng)，均需要?jiǎng)e人協(xié)助。共患的軀體及感覺(jué)障礙經(jīng)常是參加家庭、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。闡明：嚴(yán)重水平是通過(guò)適應(yīng)功效，而非IQ水平來(lái)定義，由于所需協(xié)助的水平是由適應(yīng)功效決定的。另外，在低值IQ測(cè)試的可信度較低。診療特點(diǎn)：智力障礙的基本特性是全方面心智能力的缺點(diǎn)（診療原則A），及于個(gè)體在年紀(jì)、性別、社會(huì)文化相匹配的對(duì)照的日常適應(yīng)功效的障礙（診療原則B），起病與發(fā)育時(shí)期（診療原則C），診療應(yīng)當(dāng)基于臨床評(píng)定及原則化的智力和適應(yīng)功效評(píng)測(cè)的結(jié)合。DSM涉及到的調(diào)節(jié)：適應(yīng)功效構(gòu)造的調(diào)節(jié)：DSM5將DSMIVTR中，適應(yīng)功效涵蓋涉及溝通交際、自我照顧、居家生活、社會(huì)／人際技能、社會(huì)資源運(yùn)用、自我批示、功效性學(xué)科技能、工作、休閑娛樂(lè)、健康和安全等10個(gè)方面，在其中最少兩個(gè)方面存在缺點(diǎn)即可認(rèn)為適應(yīng)功效存在缺點(diǎn)，調(diào)節(jié)為概念、社交和實(shí)用三個(gè)領(lǐng)域，并規(guī)定在其中一種領(lǐng)域存在缺點(diǎn)即可診療為適應(yīng)功效缺點(diǎn)。分類原則的調(diào)節(jié)：DSM5將DSMIVTR中根據(jù)IQ分?jǐn)?shù)對(duì)智力障礙進(jìn)行分類調(diào)節(jié)為根據(jù)個(gè)體適應(yīng)功效缺點(diǎn)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)域的體現(xiàn)?！坝捎谒鑵f(xié)助的水平是由適應(yīng)功效決定的。另外，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)的因素涉及練習(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))。”“智商測(cè)評(píng)分?jǐn)?shù)是對(duì)概念功效的粗略預(yù)計(jì),不能充足地評(píng)定現(xiàn)實(shí)生活狀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)功效的其它領(lǐng)域上有嚴(yán)重的適應(yīng)性行為問(wèn)題,以致其實(shí)際功效與智商得分更低的個(gè)體的體現(xiàn)相稱,因此,在解釋智商測(cè)評(píng)的成果時(shí)需要臨床判斷”障礙發(fā)生時(shí)間的調(diào)節(jié)：DSM5將DSMIVTR中診療原則是障礙發(fā)生在18歲以前調(diào)節(jié)為發(fā)育時(shí)期。由于由于智力障礙成因的復(fù)雜性，很難嚴(yán)格定義障礙發(fā)生時(shí)間的范疇，故而采用了更為寬泛的體現(xiàn)。附：DSM5原文Intellectualdisability(intellectualdevelopmentaldisorder)isadisorderwithonsetduringthedevelopmentalperiodthatincludesbothintellectualandadaptivefunctioningdeficitsinconceptual,social,andpracticaldomains.Thefollowingthreecriteriamustbemet:Deficitsinintellectualfunctions,suchasreasoning,problemsolving,planning,abstractthinking,judgment,academiclearning,andlearningfromexperience,confirmedbybothclinicalassessmentandindividualized,standardizedintelligencetesting.Deficitsinadaptivefunctioningthatresultinfailuretomeetdevelopmentalandsocio-culturalstandardsforpersonalindependenceandsocialresponsibility.Withoutongo-ingsupport,theadaptivedeficitslimitfunctioninginoneormoreactivitiesofdailylife,suchascommunication,socialparticipation,andindependentliving,acrossmultipleenvironments,suchashome,school,work,andcommunity.Onsetofintellectualandadaptivedeficitsduringthedevelopmentalperiod.Note:ThediagnostictermintellectualdisabilityistheequivalenttermfortheICD-11diag-nosisofintellectualdevelopmentaldisorders.Althoughthetermintellectualdisabilityisusedthroughoutthismanual,bothtermsareusedinthetitletoclarifyrelationshipswithotherclassificationsystems.Moreover,afederalstatuteintheUnitedStates(PublicLaw111-256,Rosa’sLaw)replacesthetermmentalretardationwithintellectualdisability,andresearchjournalsusetheterminte//ecfua/disability.Thus,intellectualdisabilityisthetermincommonusebymedical,educational,andotherprofessionsandbythelaypublicandadvocacygroups.Codingnote:TheICD-9-CMcodeforintellectualdisability(intellectualdevelopmentaldisorder)is319,whichisassignedregardlessoftheseverityspecifier.TheICD-10-CMcodedependsontheseverityspecifier(seebelow).Specifycurrentseverity(seeTable1):(F70)Mild(F71)Moderate(F72)Severe(F73)ProfoundSpecifiersThevariouslevelsofseverityaredefinedonthebasisofadaptivefunctioning,andnotIQscores,becauseitisadaptivefunctioningthatdeterminesthelevelofsupportsrequired.Moreover,IQmeasuresarelessvalidinthelowerendoftheIQrange.DiagnosticFeaturesTheessentialfeaturesofintellectualdisability(intellectualdevelopmentaldisorder)aredeficitsingeneralmentalabilities(CriterionA)andimpairmentineverydayadaptivefunctioning,incomparisontoanindividual’sage-,gender-,andsocioculturallymatchedpeers(CriterionB).Onsetisduringthedevelopmentalperiod(CriterionC).Thediagnosisofintellectualdisabilityisbasedonbothclinicalassessmentandstandardizedtestingofintellectualandadaptivefunctions.TABLE1Severitylevelsforintellectualdisability(intellectualdevelopmentaldisorder)SeveritylevelConceptualdomainSocialdomainPracticaldomainMildForpreschoolchildren,theremaybenoobviousconceptualdifferences.Forschool-agechildrenandadults,therearedifficultiesinlearningaca-demicskillsinvolvingreading,writing,arithmetic,time,ormoney,withsupportneededinoneormoreareastomeetage-relatedexpectations.Inadults,abstractthinking,exec-utivefunction(i.e.,planning,strategizing,prioritysetting,andcognitiveflexibility),andshort-termmemory,aswellasfunctionaluseofacademicskills(e.g.,reading,moneymanagement),areimpaired.Thereisasomewhatconcreteapproachtoproblemsandsolutionscomparedwithage-mates.Comparedwithtypicallydevelopingage-mates,theindividualisimmatureinsocialinteractions.Forexample,theremaybediffi-cultyinaccuratelyperceivingpeers’socialcues.Communication,conversation,andlan-guagearemoreconcreteorimmaturethanexpectedforage.Theremaybedifficultiesreg-ulatingemotionandbehaviorinage-appropri-atefashion;thesedifficultiesarenoticedbypeersinsocialsituations.Thereislimitedunderstandingofriskinsocialsituations;socialjudgmentisimmatureforage,andthepersonisatriskofbeingmanipulatedbyothers(gullibility).Theindividualmayfunctionage-appropriatelyinpersonalcare.Individualsneedsomesupportwithcomplexdailylivingtasksincomparisontopeers.Inadulthood,supportstypicallyinvolvegroceryshop-ping,transportation,homeandchild-careorganic-ing,nutritiousfoodpreparation,andbankingandmoneymanagement.Recreationalskillsresemblethoseofage-mates,althoughjudgmentrelatedtowell-beingandorganizationaroundrecreationrequiressupport.Inadulthood,competitiveemploymentisoftenseeninjobsthatdonotempha-sizeconceptualskills.Individualsgenerallyneedsupporttomakehealthcaredecisionsandlegaldecisions,andtolearntoperformaskilledvocationcompetently.Supportistypicallyneededtoraiseafamily.TABLE1Severitylevelsforintellectualdisability(intellectualdevelopmentaldisorder){continued]SeveritylevelConceptualdomainSocialdomainPracticaldomainModerateAllthroughdevelopment,theindividual’sconceptualskillslagmarkedlybehindthoseofpeers.Forpreschoolers,lan-guageandpre-academicskillsdevelopslowly.Forschool-agechildren,progressinreading,writing,mathematics,andunderstandingoftimeandmoneyoccursslowlyacrosstheschoolyearsandismark-edlylimitedcomparedwiththatofpeers.Foradults,aca-demicskilldevelopmentistypicallyatanelementarylevel,andsupportisrequiredforalluseofacademicskillsinworkandpersonallife.Ongo-ingassistanceonadailybasisisneededtocompleteconcep-tualtasksofday-to-daylife,andothersmaytakeovertheseresponsibilitiesfullyfortheindividual.Theindividualshowsmarkeddifferencesfrompeersinsocialandcommunicativebehavioracrossdevelopment.Spokenlanguageistypi-callyaprimarytoolforsocialcommunicationbutismuchlesscomplexthanthatofpeers.Capacityforrelationshipsisevidentintiestofamilyandfriends,andtheindividualmayhavesuccessfulfriendshipsacrosslifeandsometimesromanticrelationsinadulthood.However,individualsmaynotperceiveorinterpretsocialcuesaccurately.Socialjudg-mentanddecision-makingabilitiesarelim-ited,andcaretakersmustassistthepersonwithlifedecisions.Friendshipswithtypicallydevelopingpeersareoftenaffectedbycom-municationorsociallimitations.Significantsocialandcommunicativesupportisneededinworksettingsforsuccess.Theindividualcancareforpersonalneedsinvolvingeating,dressing,elimination,andhygieneasanadult,althoughanextendedperiodofteachingandtimeisneededfortheindividualtobecomeindepen-dentintheseareas,andremindersmaybeneeded.Similarly,participationinallhouseholdtaskscanbeachievedbyadulthood,althoughanextendedperiodofteachingisneeded,andongoingsupportswilltypicallyoccurforadult-levelperformance.Independentemploymentinjobsthatrequirelim-itedconceptualandcommunicationskillscanbeachieved,butconsiderablesupportfromco-work-ers,supervisors,andothersisneededtomanagesocialexpectations,jobcomplexities,andancillaryresponsibilitiessuchasscheduling,transportation,healthbenefits,andmoneymanagement.Avarietyofrecreationalskillscanbedeveloped.Thesetypi-callyrequireadditionalsupportsandlearningopportunitiesoveranextendedperiodoftime.Maladaptivebehaviorispresentinasignificantminorityandcausessocialproblems.TABLE1Severitylevelsforintellectualdisability(intellectualdevelopmentaldisorder)[confinzzed)SeveritylevelConceptualdomainSocialdomainPracticaldomainSevereAttainmentofconceptualskillsislimited.Theindividualgen-erallyhaslittleunderstandingofwrittenlanguageorofcon-ceptsinvolvingnumbers,quantity,time,andmoney.Caretakersprovideextensivesupportsforproblemsolvingthroughoutlife.Spokenlanguageisquitelimitedintermsofvocabularyandgrammar.Speechmaybesin-glewordsorphrasesandmaybesupple-mentedthroughaugmentativemeans.Speechandcommunicationarefocusedonthehereandnowwithineverydayevents.Languageisusedforsocialcommunicationmorethanforexplication.Individualsunderstandsimplespeechandgesturalcommunication.Relation-shipswithfamilymembersandfamiliarothersareasourceofpleasureandhelp.Theindividualrequiressupportforallactivitiesofdailyliving,includingmeals,dressing,bathing,andelimination.Theindividualrequiressupervisionatalltimes.Theindividualcannotmakeresponsibledecisionsregardingwell-beingofselforothers.Inadulthood,participationintasksathome,recre-ation,andworkrequiresongoingsupportandassis-tance.Skillacquisitioninalldomainsinvolveslong-termteachingandongoingsupport.Maladaptivebehavior,includingself-injury,ispresentinasignif-icantminority.ProfoundConceptualskillsgenerallyinvolvethephysicalworldratherthansymbolicpro-cesses.Theindividualmayuseobjectsingoal-directedfashionforself-care,work,andrecre-ation.Certainvisuospatialskills,suchasmatchingandsortingbasedonphysicalchar-acteristics,maybeacquired.However,co-occurringmotorand