DSM 5智力障礙診療實用標準及原文

診療原則：智力障礙（智力發(fā)育障礙）是起病于發(fā)育時期，在概念、社交和實用領域中的智力和適應功效的缺點。須符合下列三個診療原則：A經臨床評定和個體化、原則化的智力評測確認的智力功效障礙，如推理、問題解決、計劃、抽象思維、判斷、學業(yè)學習和基于經驗的學習。B適應功效缺點造成未能達成發(fā)育及社會文化相稱的個人獨立性及社會責任原則。在沒有持續(xù)協(xié)助的狀況下，該適應功效缺點限制了其在多個環(huán)境中，如家庭、學校、工作和社區(qū)，的一種或多個日常生活功效，如交流、社會參加和獨立生活。C智力和適應缺點起病于發(fā)育時期。嚴重程度則基于ICD-10-CM編碼以下：嚴重度概念領域社交領域實用領域輕在學齡前小朋友，可能沒有明顯的概念區(qū)別。對于學齡小朋友和成人，存在學習困難，涉及讀、寫、計算、時間金錢的概念，在一種或多個領域需要協(xié)助以達成年紀預期的水平。在成人，則有抽象思維、執(zhí)行功效（如計劃、方略、最優(yōu)設定及認知靈活性）、短時記憶以及對學業(yè)能力的應用（如讀、財務管理）的受損。對于問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、對話和語言相較于匹配年紀更為具體化及不成熟。往往能被同伴注意到其在以年紀相稱的方式控制行為及情緒方面存在困難。難以完全體會到社交風險，社交判斷不成熟，存在被別人控制的風險（被騙）。在個人護理方面其能力與年紀相稱。但是在復雜的日常生活行為上與同齡相較需要協(xié)助。在成人身上，購物、交通、家務及照顧小朋友及財務管理等方面需要協(xié)助。娛樂活動的技能則與同齡人相近，但是在安全有關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)生及法律有關決策以及學習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。嚴重度概念領域社交領域實用領域中即使有在成長，但是概念技巧落后于同齡兒。在學齡前小朋友，語言能力及入學前學業(yè)技巧發(fā)展緩慢。在學齡期小朋友，讀、寫、計算、理解時間和金錢方面進展緩慢，并且與同伴相較明顯受限。在成人，學業(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學業(yè)技巧的地方均需要協(xié)助。完畢日常生活中概念性任務時需要持續(xù)的協(xié)助，甚至需要別人完全接管。在整個發(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，但是與同齡兒相比明顯的更簡樸。發(fā)展關系明顯與家庭及朋友有關，但個體可能在人生中獲得成功的友情關系甚至在成人期獲得浪漫關系。然而個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)護人需要在生活決策提供協(xié)助。與正常個體發(fā)展友情經常為交流及社會能力的局限所影響。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，能夠完畢諸如進食、穿衣、排泄及衛(wèi)生等個人需求。即使需要更多的教育及時間才干在這些方面獲得獨立，并且需要人提示。對應的，成人期亦可完畢在家務活動，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)助來應對涉及到社會盼望、復雜性工作及附帶責任的如計劃安排、交通、健康福利及財務管理。個體可發(fā)展出色多的娛樂技能。但往往需要額外的協(xié)助及時間來教學。極個別的存在適應性不良行為并造成社會問題。嚴重度概念領域社交領域實用領域重概念化技能的習得有限。個體普通對書面語言及涉及到數(shù)字、數(shù)量、時間及金錢的概念理解有限。在一身中監(jiān)護人均需要提供解決問題的額外協(xié)助。在詞匯及語法方面?zhèn)€體的口語水平有限。話語可能是單獨的字或詞，以及可能通過輔助的方式補充。交流的內容局限于當下的日常生活事件。語言更多地用于社會交流而不是體現(xiàn)。個體能夠理解簡樸的演講及手勢交流。同家庭組員及熟悉個體的關系是愉快及協(xié)助的來源。個體在日常生活的全部活動均需要協(xié)助，涉及進食、穿衣、洗澡級排泄。在任何時間個體均需要監(jiān)護。個體無法在涉及自己及別人安全上做出負責任的決策。在成人，參加家庭任務、娛樂及工作均需要協(xié)助。在全部領域的技能均需要長久的教學及不停的協(xié)助。不適應行為，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體世界而非象征性過程。個體能夠使用對象通過目的導向的方式完畢自我照顧、工作及娛樂。某些特定的視覺空間技能，如通過物質特性匹配和排序可能能夠習得。然而，共患的動作及感覺障礙可能影響對物體的功效使用。個體對于語言或手勢的象征性交流的理解十分局限，可能理解某些簡樸的指導或手勢。其體現(xiàn)自己的需求和感情大多通過非語言非象征的交流方式。個體享有同熟悉的家庭組員、監(jiān)護人、熟人的關系，并且通過手勢或情感線索發(fā)起或回應社交互動。共患的感覺或軀體損傷可能影響某些社會行為。個體在身體照顧、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。沒有嚴重軀體損傷的個體能夠協(xié)助某些家庭的日常工作，如端菜上桌。使用物體的簡樸活動可能是在高度持續(xù)的協(xié)助下參加某些職業(yè)活動的基礎。娛樂活動可能涉及，如享有音樂、看電影、散步、水上活動，均需要別人協(xié)助。共患的軀體及感覺障礙經常是參加家庭、娛樂及工作活動的障礙（除了觀看）。在極少數(shù)個體存在不適應行為。闡明：嚴重水平是通過適應功效，而非IQ水平來定義，由于所需協(xié)助的水平是由適應功效決定的。另外，在低值IQ測試的可信度較低。診療特點：智力障礙的基本特性是全方面心智能力的缺點（診療原則A），及于個體在年紀、性別、社會文化相匹配的對照的日常適應功效的障礙（診療原則B），起病與發(fā)育時期（診療原則C），診療應當基于臨床評定及原則化的智力和適應功效評測的結合。DSM涉及到的調節(jié)：適應功效構造的調節(jié)：DSM5將DSMIVTR中，適應功效涵蓋涉及溝通交際、自我照顧、居家生活、社會／人際技能、社會資源運用、自我批示、功效性學科技能、工作、休閑娛樂、健康和安全等10個方面，在其中最少兩個方面存在缺點即可認為適應功效存在缺點，調節(jié)為概念、社交和實用三個領域，并規(guī)定在其中一種領域存在缺點即可診療為適應功效缺點。分類原則的調節(jié)：DSM5將DSMIVTR中根據(jù)IQ分數(shù)對智力障礙進行分類調節(jié)為根據(jù)個體適應功效缺點的嚴重程度將智力障礙標注為輕度、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、社交和實用領域的體現(xiàn)。“由于所需協(xié)助的水平是由適應功效決定的。另外，在低值IQ測試的可信度較低?！辈⑶摇翱赡苡绊憸y評分數(shù)的因素涉及練習效應和“Flynn效應”(即由于過時的測評常模造成過高分數(shù))?！薄爸巧虦y評分數(shù)是對概念功效的粗略預計,不能充足地評定現(xiàn)實生活狀況中的推理能力和對實用任務的掌握能力,例如,智商得分70以上的個體可能在社交判斷、社交理解和適應功效的其它領域上有嚴重的適應性行為問題,以致其實際功效與智商得分更低的個體的體現(xiàn)相稱,因此,在解釋智商測評的成果時需要臨床判斷”障礙發(fā)生時間的調節(jié)：DSM5將DSMIVTR中診療原則是障礙發(fā)生在18歲以前調節(jié)為發(fā)育時期。由于由于智力障礙成因的復雜性，很難嚴格定義障礙發(fā)生時間的范疇，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