DSM 5智力障碍诊断实用标准及原文

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 中 概念领域 社交领域 实用领域 虽然有在成长，但是概念技在整个发育阶段，社交及交流行为与同作为成年人，可以完成诸如进食、穿衣、排泄巧落后于同龄儿。在学龄龄儿相比有显著不同。 通常主要的交及卫生等个人需求。虽然需要更多的教育及时前儿童，语言能力及入学流方式是口语，但是与同龄儿相比显著间才能在这些方面获得独立，并且需要人提前学业技巧发展缓慢。在的更简单。 醒。 学龄期儿童，读、写、计发展关系显著与家庭及朋友相关，但个相应的，成人期亦可完成在家务活动，但是同算、理解时间和金钱方面体可能在人生中获得成功的友情关系样需要额外的教育，并且要完成成人水平的进展缓慢，并且与同伴相甚至在成人期获得浪漫关系。然而个体工作往往需要持续帮助。 较明显受限。 可能不能准确的接受或解读社交线索。 个体作为雇员可以完成需要有限的概念及在成人，学业能力发展典型社交判断及决策能力有限，监护人需要交流技巧的工作，但需要同事、上司等的帮而言仅限于初级水平，在在生活决策提供帮助。 与正常个体发助来应对涉及到社会期望、复杂性工作及附工作和生活中需要学业技展友谊经常为交流及社会能力的局限带责任的如计划安排、交通、健康福利及财巧的地方均需要帮助。完所影响。在需要成功完成的工作上，显务管理。 成日常生活中概念性任务著的需要社交及交流的帮助。

严重度 重 概念领域 社交领域 实用领域 个体在日常生活的所有活动均需要帮助，包括概念化技能的习得有限。个在词汇及语法方面个体的口语水平有体通常对书面语言及涉及限。话语可能是单独的字或词，以及可进食、穿衣、洗澡级排泄。在任何时间个体交流的容局限均需要监护。个体无法在涉及自己及他人安到数字、数量、时间及金能通过辅助的方式补充。语言更多地用全上做出负责任的决策。在成人，参与家庭钱的概念理解有限。在一于当下的日常生活事件。个体能够理解任务、娱乐及工作均需要帮助。在所有领域身中监护人均需要提供解于社会交流而不是表达。简单的演讲及手势交流。同家庭成员及的技能均需要长期的教学及不断的帮助。不决问题的额外帮助。 熟悉个体的关系是快乐及帮助的来源。 适应行为，如自残，在极少数群体中有表现。 概念化技巧往往涉及实体个体对于语言或手势的象征性交流的理个体在身体照顾、健康及安全方面完全依赖于世界而非象征性过程。个解十分局限，可能理解一些简单的指导他人，虽然其可能也能够参与其中一些活动。体能够使用对象通过目标或手势。其表达自己的需求和感情大多没有严重躯体损伤的个体可以协助一些家庭导向的方式完成自我照通过非语言非象征的交流方式。 的日常工作，如端菜上桌。使用物体的简单顾、工作及娱乐。 活动可能是在高度持续的协助下参与一些职个体享受同熟悉的家庭成员、监护人、业活动的基础。娱乐活动可能涉及，如享受一些特定的视觉空间技能，熟人的关系，并且通过手势或情感线索音乐、看电影、散步、水上活动，均需要他如通过物质特性匹配和排发起或回应社交互动。共患的感觉或躯人帮助。共患的躯体及感觉障碍常常是参与序可能可以习得。然而，体损伤可能影响一些社会行为。 家庭、娱乐及工作活动的障碍（除了观看）。共患的动作及感觉障碍可在极少数个体存在不适应行为。 能影响对物体的功能使显著 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 Mild Social domain 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). Practical domain 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. 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. TABLE 1 Severity levels for intellectual disability (intellectual developmental disorder) {continued]

Severity level Conceptual domain Social domain 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 - munication or social limitations. Significant social and communicative support is needed in work settings for success. Practical domain 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. 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. TABLE 1 Severity levels for intellectual disability (intellectual developmental disorder) [confinzzed)

Severity level Severe Conceptual domain 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. Practical domain 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. 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. Social domain 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 Caretakers provide extensive explication. Individuals understand simple supports for problem solving speech and gestural communication. Relation- throughout life. ships with family members and familiar others are a source of pleasure and help. 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 - 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. 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.