DSM 5智力障碍诊断标准及原文

诊断标准 智力障碍 智力发育障碍 是起病于发育时期 在概念 社交和实用领域中的智力和适应功能的缺陷 须符合以下三个诊断标准 A 经临床评估和个体化 标准化的智力评测确认的智力功能障碍 如推理 问题解决 计划 抽象思维 判断 学业学习和基于经 验的学习 B 适应功能缺陷造成未能达到发育及社会文化相称的个人独立性及社会责任标准 在没有持续帮助的情况下 该适应功能缺陷限制 了其在多个环境中 如家庭 学校 工作和社区 的一个或多个日常生活功能 如交流 社会参与和独立生活 C 智力和适应缺陷起病于发育时期 严重程度则基于 ICD 10 CM 编码如下 严重度 概念领域 社交领域 实用领域 轻 在学龄前儿童 可能没有 明显的概念区别 对于学 龄儿童和成人 存在学习 困难 包括读 写 计算 时间金钱的概念 在一个 或多个领域需要帮助以达 到年龄预期的水平 在成 人 则有抽象思维 执行 功能 如计划 策略 最 优设定及认知灵活性 短时记忆以及对学业能力 的应用 如读 财务管理 的受损 对于问题及解决 方案相较于同龄人更显得 具体化 相较之下 其社交技巧不成熟 比如 在准确感知同伴的社交线索方面存在 困难 交流 对话和语言相较于匹配 年龄更为具体化及不成熟 往往能被 同伴注意到其在以年龄相称的方式控 制行为及情绪方面存在困难 难以完 全体会到社交风险 社交判断不成熟 存在被他人控制的风险 受骗 在个人护理方面其能力与年龄相称 但是在 复杂的日常生活行为上与同龄相较需要帮助 在成人身上 购物 交通 家务及照顾儿童 及财务管理等方面需要帮助 娱乐活动的技 能则与同龄人相近 不过在安全相关及组织 方面任需要帮助 在成人 可胜任不需要抽 象思维的的工作 在作出医疗卫生及法律相 关决策以及学习胜任完成熟练技巧性的工作 等方面需要帮助 在供养家庭方面也是典型 的需要帮助 严重度 概念领域 社交领域 实用领域 中 虽然有在成长 但是概念 技巧落后于同龄儿 在学 龄前儿童 语言能力及入 学前学业技巧发展缓慢 在学龄期儿童 读 写 计算 理解时间和金钱方 面进展缓慢 并且与同伴 相较明显受限 在成人 学业能力发展典 型而言仅限于初级水平 在工作和生活中需要学业 技巧的地方均需要帮助 完成日常生活中概念性任 务时需要持续的帮助 甚 至需要他人完全接管 在整个发育阶段 社交及交流行为与同 龄儿相比有显著不同 通常主要的交 流方式是口语 但是与同龄儿相比显 著的更简单 发展关系显著与家庭及朋友相关 但个 体可能在人生中获得成功的友情关系 甚至在成人期获得浪漫关系 然而个 体可能不能准确的接受或解读社交线 索 社交判断及决策能力有限 监护 人需要在生活决策提供帮助 与正常 个体发展友谊经常为交流及社会能力 的局限所影响 在需要成功完成的工 作上 显著的需要社交及交流的帮助 作为成年人 可以完成诸如进食 穿衣 排 泄及卫生等个人需求 虽然需要更多的教育 及时间才能在这些方面获得独立 并且需要 人提醒 相应的 成人期亦可完成在家务活动 但是 同样需要额外的教育 并且要完成成人水 平的工作往往需要持续帮助 个体作为雇员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 帮助来应对涉及到社会期望 复杂性工作 及附带责任的如计划安排 交通 健康福 利及财务管理 个体可发展出众多的娱乐技能 但往往需 要额外的帮助及时间来教学 极个别的存 在适应性不良行为并导致社会问题 严重度 概念领域 社交领域 实用领域 重 概念化技能的习得有限 个体通常对书面语言及涉 及到数字 数量 时间及 金钱的概念理解有限 在 一身中监护人均需要提供 解决问题的额外帮助 在词汇及语法方面个体的口语水平有限 话语可能是单独的字或词 以及可能 通过辅助的方式补充 交流的内容局 限于当下的日常生活事件 语言更多 地用于社会交流而不是表达 个体能 够理解简单的演讲及手势交流 同家 庭成员及熟悉个体的关系是快乐及帮 助的来源 个体在日常生活的所有活动均需要帮助 包 括进食 穿衣 洗澡级排泄 在任何时间个 体均需要监护 个体无法在涉及自己及他人 安全上做出负责任的决策 在成人 参与家 庭任务 娱乐及工作均需要帮助 在所有领 域的技能均需要长期的教学及不断的帮助 不适应行为 如自残 在极少数群体中有表 现 显著 概念化技巧往往涉及实体 世界而非象征性过程 个 体能够使用对象通过目标 导向的方式完成自我照顾 工作及娱乐 一些特定的视觉空间技能 如通过物质特性匹配和排 序可能可以习得 然而 共患的动作及感觉障碍可 能影响对物体的功能使用 个体对于语言或手势的象征性交流的理 解十分局限 可能理解一些简单的指 导或手势 其表达自己的需求和感情 大多通过非语言非象征的交流方式 个体享受同熟悉的家庭成员 监护人 熟人的关系 并且通过手势或情感线 索发起或回应社交互动 共患的感觉 或躯体损伤可能影响一些社会行为 个体在身体照顾 健康及安全方面完全依赖 于他人 虽然其可能也能够参与其中一些活 动 没有严重躯体损伤的个体可以协助一些 家庭的日常工作 如端菜上桌 使用物体的 简单活动可能是在高度持续的协助下参与一 些职业活动的基础 娱乐活动可能涉及 如 享受音乐 看电影 散步 水上活动 均需 要他人帮助 共患的躯体及感觉障碍常常是 参与家庭 娱乐及工作活动的障碍 除了观 看 在极少数个体存在不适应行为 说明 严重水平是通过适应功能 而非 IQ 水平来定义 因为所需帮助的水平是由适应功能 决定的 此外 在低值 IQ 测试的可信度较低 诊断特点 智力障碍的基本特征是全面心智能力的缺陷 诊断标准 A 及于个体在年龄 性别 社会文化相匹配的对照的日常适应功能的障碍 诊断标准 B 起病与发育时期 诊 断标准 C 诊断应该基于临床评估及标准化的智力和适应功能评测的结合 DSM 涉及到的调整 1 适应功能结构的调整 DSM 5 将 DSM IV TR 中 适应功能涵盖包括沟通交际 自 我照顾 居家生活 社会 人际技能 社会资源运用 自我指示 功能性学科技 能 工作 休闲娱乐 健康和安全等 10 个方面 在其中至少两个方面存在缺陷 即可认为适应功能存在缺陷 调整为概念 社交和实用三个领域 并规定在其中 一个领域存在缺陷即可诊断为适应功能缺陷 2 分类标准的调整 DSM 5 将 DSM IV TR 中根据 IQ 分数对智力障碍进行分类调整 为根据个体适应功能缺陷的严重程度将智力障碍标注为轻度 中度 重度和极重 度四种 并列举出了轻度 中度 重度和极重度患者在概念 社交和实用领域的 表现 因为所需帮助的水平是由适应功能决定的 此外 在低值 IQ 测试的可 信度较低 并且 可能影响测评分数的因素包括练习效应和 Flynn 效应 即由于过时的测评常模造成过高分数 智商测评分数是对概念功能的粗 略估计 不能充分地评估现实生活情况中的推理能力和对实用任务的掌握能力 例如 智商得分 70 以上的个体可能在社交判断 社交理解和适应功能的其他领域 上有严重的适应性行为问题 以致其实际功能与智商得分更低的个体的表现相当 因此 在解释智商测评的结果时需要临床判断 3 障碍发生时间的调整 DSM 5 将 DSM IV TR 中诊断标准是障碍发生在 18 岁以前 调整为发育时期 因为由于智力障碍成因的复杂性 很难严格定义障碍发生时间 的范围 故而采取了更为宽泛的表达 附 DSM 5 原文 Intellectual disability intellectual developmental 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 planning 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 personal 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 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 used in the title to clarify relationships with other classification systems Moreover a federal statute in the United States Public Law 111 256 Rosa s Law replaces the term mental retardation with intellectual disability and research journals use the term inte ecfua disability Thus intellectual 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 10 CM code depends on the severity specifier see below Specify current severity see Table 1 F70 Mild F71 Moderate F72 Severe F73 Profound Specifiers The various levels of severity are defined on the basis of adaptive functioning and not IQ scores because it is adaptive functioning that determines the level of supports required Moreover IQ measures are less valid in the lower end of the IQ range Diagnostic Features The essential features of intellectual disability intellectual developmental disorder are deficits in general mental abilities Criterion A and impairment in everyday adaptive functioning in comparison to an individual s 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 adaptive functions TABLE 1 Severity levels for intellectual disability intellectual developmental disorder Severity level Conceptual domain Social domain Practical domain Mild For preschool children there may be no obvious conceptual differences For school age children and adults there are difficulties 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 term 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 with age mates Compared with typically developing age mates the individual is immature in social interactions For example 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 in social situations There is limited understanding of risk in social situations social judgment is immature for age and the 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 daily 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 being 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 Support is typically needed to raise a family TABLE 1 Severity levels for intellectual disability intellectual developmental disorder continued Severity level Conceptual domain Social domain Practical domain Moderate All through development the individual s conceptual skills lag markedly behind those of 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 skill 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 individual 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 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 decisions 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 adult 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 supports 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 responsibilities 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 minority and causes social problems TABLE 1 Severity levels for intellectual disability intellectual developmental disorder confinzzed Severity level Conceptual domain Social domain Practical domain Severe Attainment of conceptual skills is limited The individual gen erally has little understanding of written 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 augmentative 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 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 participation 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 Profound Conceptual skills generally involve 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 limited understanding of symbolic communication in speech or ges ture He or she may understand some simple instructions or gestures The individual expresses his or her own desires and emotions largely through nonverbal nonsymbolic com munication The individual enjoys relation ships with well known family members caretakers and familiar others and initiates and responds to social interactions through gestural and emotional cues Co occurring sensory and physical impairments may pre vent many social activities The individual is dependent on others for all aspects of daily physical care health and safety although he or she may be able to participate in some of these activi ties as well Individuals without severe physical impairments may assist with some daily work tasks at home like carrying dishes to the table Simple actions with objects may be the basis of participation in some vocational activities with high levels of ongoing sup port Recreational activities may involve for example enjoyment in listening to music watching movies going out for walks or participating in water activi ties all with the support of others Co occurring physical and sensory impairments are frequent barriers to participation beyond watching in home recreational and vocational activities Maladaptive behavior is present in a significant minority