发育障碍是一个伞,它广泛地指的是一组严重和慢性的身体或精神障碍,其特征是缺乏或延迟达到某些代表正常发展的人的发展里程碑。智力低下(MR)是一种发育障碍,在认知和适应性功能中存在缺陷来体现。具有MR的个体个人功能模式大大有限,尽管这些模式因人而异,具体取决于缺陷的严重性和类型。与任何发育障碍一样,MR个体功能的局限性是由婴儿期或幼儿期表现出来的,并且本质上是终生的。
The Nature of Mental Retardation and Developmental Disabilities
Diagnostic Criteria
MR的诊断标准在精神障碍的诊断和统计手册中列出,第四版,文本修订(DSM - IV -TR)在“通常在婴儿期,童年和青春期首次诊断的疾病的标题下”,也可以是found in the American Association on Mental Retardation’s (AAMR) Mental Retardation: Definition, Classification, and Systems of Supports, Tenth Edition. (Note: The AAMR has changed its name to the American Association on Intellectual and Developmental Disabilities.)
为了保证对MR的诊断,在18岁之前的个体中必须存在以下两个症状:至少两个适应性功能的领域低于平均水平的智力功能和障碍。
Intellectual functioning is assessed using standardized instruments that measure an individual’s intelligence quotient (IQ), such as the Wechsler Adult Intelligence Scale—Third Edition and the Stanford-Binet Intelligence Scales, Fifth Edition. Standardized IQ scores exist along a normal continuum, where a mean IQ score of 100 (standard deviation of 15) reflects an individual with average intelligence. To be considered for an MR diagnosis, individuals must have an IQ score approximately two standard deviations below the mean. This means that an IQ score of approximately 70 or below is needed to demonstrate significantly subpar intellectual functioning. Moreover, intellectual functioning is also coded to reflect the severity of impairment: mild (50-55 to approximately 70), moderate (35-10 to 50-55), severe (20-25 to 35-40), and profound (20-25 or below). Unspecified is the code given when there is a strong suspicion of MR, but actual IQ scores cannot be determined due to factors that interfere with IQ testing, such as uncooperativeness or extremely impaired functioning.
自适应功能是指成功导航日常生活需求所需的活动。当个人表现出适应性功能缺陷时,他们在完成这些日常活动时表现出一致的无效性。根据个人的年龄年龄,考虑自适应功能的水平,并使用标准化评估工具进行测量,例如Vineland自适应行为量表,第二版和AAMR自适应行为量表,第二版。考虑到MR诊断的自适应功能的广泛领域包括日常生活技能,沟通技巧以及社交和人际交往能力。日常生活技能是指一系列行为,这些行为以自我保健,家务,工作或学术参与以及获得社区资源的能力为中心。沟通技巧涉及准确理解他人并表达自己的能力。社交和人际交往能力是成功与他人互动,应对日常压力并利用空闲时间所需的技能。除这三个领域外,还可以在儿童中评估精细和总体运动技能(例如厕所训练和步行)的缺陷。
In addition to intellectual functioning and adaptive functioning, the AAMR definition of MR goes a step further and integrates a skills-based component to shift the focus away from the solely limitations-based definition given by the DSM-IV-TR. For example, the AAMR definition of MR addresses the context of the individual’s limitations, strengths, and available environmental supports. Both the DSM-IV-TR and the AAMR suggest that before a diagnosis of MR is rendered, it is imperative to rule out medical conditions, cultural and language considerations, and physical limitations (e.g., hearing or visual impairments) that may interfere with normal development or current functioning. In addition, developmental issues should be taken into account when assessing adaptive functioning; for example, it would be inappropriate to measure occupational performance when assessing the adaptive functioning of a child.
原因
A variety of genetic, chromosomal, and environmental causal sources have been linked to MR. Genetic and chromosomal disorders are thought to account for approximately half of MR cases, with the other half due to environmental or unknown causes. Examples of genetic and chromosomal types of disorders include the following: metabolic disorders (e.g., phenylketonuria, galactosemia) and chromosomal abnormalities (Down syndrome, Klinefelter’s syndrome, fragile X). Environmental causes include chronic and severe neglect of basic needs (e.g., food, affection), teratogen exposure in utero (e.g., fetal alcohol syndrome, Food and Drug Administration pregnancy category D- and X-classed drugs), fetal and infant malnutrition, and birth complications (e.g., hypoxia, premature delivery).
发病率
大多数可靠的来源,例如疾病控制和预防中心以及AAMR,将MR的患病率定为大约1%至3%的普通人群。在不同的社会经济类别中,遗传和染色体因子引起的MR发生率类似。环境原因(例如,铅中毒和营养不良)似乎更常见于社会经济地位较低的个体中。此外,MR似乎以较高的频率发生在男性中(男性为1.5至1位女性)。温和的MR更为普遍,约占该组所有个体的85%。中度MR发生在10%时,严重的MR对应于所有MR病例的3%,而大约1%的此类个体发生了深刻的MR。总的来说,患有MR的人的慢性身心健康障碍率与普通人群相同。例外是由于某些疾病(例如代谢性疾病)所特有的有问题的症状,以及MR深刻的个体中存在神经系统异常和身体局限性。
变化和挑战
治疗干预措施
MR的干预措施直接针对自适应生活技能,并考虑到个人的局限性和优势。干预措施通常解决增加的自决,针对有问题的行为,不断提高社交技能,并协助照顾者,家庭和雇主修改个人的环境以最大程度地提高成功。最好通过协调多项服务来完成这项工作,例如治疗,职业康复,社会服务,学校和护理人员。干预措施高度取决于个人的残疾水平;例如,对温和MR的个体的治疗计划将与具有更广泛限制的个体不同。一个有温和MR的人的典型例子可能是一个日间学校课程,该课程将学术课程放在日常生活的背景下,例如专注于社交技能,阅读公共汽车时间表,计算简单的预算,烹饪和家庭保养。职业培训也是推荐的治疗考虑因素,应基于个人的优势。
此外,医疗保健提供者越来越意识到,在MR人群中,心理障碍的发生率要比以前的思想和保证心理服务高得多。抑郁,焦虑,行为问题或冲动控制问题的速度很常见,并且与这些疾病的症状一致,有时会出现有害行为。针对这些行为的干预措施很重要,教学有益的应对机制(例如,休息/休息,重新引起注意)也很重要。同样,适当使用精神药物可以是可行的治疗途径。以洞察力为导向的疗法可能与温和MR的个体具有一定的用途。治疗性干预措施应着重于建模健康的情绪表达,管理人际关系和专业关系以及管理压力大的情况。
Caregiver issues
根据AAMR,趋势表明在过去30年中,州机构中的MR个体人数减少了四倍。从机构过渡到住宅环境对许多MR个人来说是有益的,因为它促进了自决,但是这种趋势以多种方式增加了护理人员和家庭的压力。所有家庭成员,尤其是兄弟姐妹,很难理解照顾个人所需的其他情感和社会支持。由MR个人的独特需求引起的财务困难可能会征税。尽管许多MR个人是减轻医疗保健经济负担的医疗补助福利的接受者,但通常很难找到会服用医疗补助患者的医生,因为报销率低于其他类型的健康保险。对护理人员和家庭的身体需求。诸如以MR提升或运送人或处理有害或其他挑战行为的活动等活动会增加压力和疲劳。协助满足这些要求家庭的非营利组织是无价的,因为它们可以帮助您解决社区资源,运输和暂息护理等问题。但是,其中许多组织都有广泛的等待名单。付费照料者通常会以低率的价格报销其服务,从而产生高的营业额和不良的护理连续性。 In general, stress and fatigue can prompt an increase in abusive and neglect-hil behaviors among caregivers. Such behaviors can be either passive (e.g., failure to respond to basic needs) or active (e.g., physical violence, verbal abuse). Regardless, attending to the psychological needs of the caregivers of MR individuals and providing social supports are important intervention considerations.
参考:
- 美国智力障碍协会。(2002)。智力低下:支持的定义,分类和系统(第10版)。华盛顿特区:作者。
- American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text rev.). Washington, DC: Author.
- American Psychological Association. (2005). Guidelines on effective behavioral treatment for persons with mental retardation and developmental disabilities. A resolution by APA Division 33.
- 疾病预防与控制中心。(2005年10月25日)。发育障碍:智力障碍。从...获得http://www.cdc.gov/ncbddd/actearly/pdf/parents_pdfs/intellectualdisability.pdf