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世界衛(wèi)生組織《殘疾評(píng)定量表》的制訂和測(cè)試
姚貴忠 舒良 沈漁邨 北京大學(xué)精神衛(wèi)生研究所 100083
目的:與WHO協(xié)作開(kāi)發(fā)一套國(guó)際通用的殘疾評(píng)定工具——WHO殘疾評(píng)定量表（Disability Assessment Schedule，DAS），測(cè)試其在中國(guó)應(yīng)用的信度、效度，初步探討評(píng)殘分界值。
方法:
1.與WHO共同制訂和測(cè)試DAS條目庫(kù)，并通過(guò)多種問(wèn)卷向殘疾者及其家屬、專(zhuān)業(yè)人員和政策制定者進(jìn)行殘疾狀況調(diào)查，然后經(jīng)過(guò)對(duì)DAS中介版本的測(cè)試，制訂出DAS最終版本。
2.以中國(guó)精神殘疾評(píng)定標(biāo)準(zhǔn)（SDSS-R）作為效標(biāo)，2名評(píng)定者對(duì)254例受試者進(jìn)行了DAS測(cè)試，測(cè)試評(píng)定者信度20例，測(cè)試重測(cè)信度100例。
3.納入50名急性發(fā)作期精神分裂癥患者，經(jīng)過(guò)8周常規(guī)治療，評(píng)定治療前后DAS對(duì)病情變化的敏感性（STC）。
結(jié)果: DAS總分及6個(gè)因子分的重測(cè)相關(guān)系數(shù)都在0.9以上，評(píng)定者信度（ICC via ANOVA）為0.997，6個(gè)因子分之間以及每個(gè)因子分與總分之間的相關(guān)都具有高度顯著性（P值均小于0.01）。因子分析的結(jié)果與原量表結(jié)構(gòu)基本相符，各因子貢獻(xiàn)率的分布與量表的理論構(gòu)想是相一致的。DAS與SDSS-R、BPRS、CGI之間的相關(guān)都具有高度顯著性（P值均小于0.01），提示DAS與三者之間的平行效度良好。經(jīng)過(guò)8周臨床治療，隨著B(niǎo)PRS和CGI得分的顯著下降，DAS及其5個(gè)因子分的下降亦有顯著性。本研究以SDSS-R的評(píng)分結(jié)果為基礎(chǔ)，初步設(shè)定DAS的評(píng)殘分界值為：51分以下無(wú)殘疾，52-94分輕度，95-115分中度，116分以上重度，兩種評(píng)殘方法具有高度一致性（Kappa=0.592, P<0.01）。
結(jié)論: DAS的各項(xiàng)信度、效度指標(biāo)均達(dá)到心理測(cè)量學(xué)要求，可以作為一種新的殘疾評(píng)定工具使用，它的開(kāi)發(fā)對(duì)推動(dòng)殘疾問(wèn)題的研究意義重大。
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DSM-IV Axis V consisted of the Global Assessment of Functioning (GAF) scale, representingthe clinician's judgment of the individual's overall level of "functioning on a hypotheticalcontinuum of mental health-illness." It was recommended that the GAF bedropped from DSM-5 for several reasons, including its conceptual lack of clarity (i.e., includingsymptoms, suicide risk, and disabilities in its descriptors) and questionable psychometricsin routine practice. In order to provide a global measure of disability, the WHODisability Assessment Schedule (WHODAS) is included, for further study, in Action III ofDSM-5 (see the chapter "Assessment Measures"). The WHODAS is based on the InternationalClassification of Functioning, Disability and Health (ICF) for use across all of medicineand health care. The WHODAS (version 2.0), and a modification developed for children/adolescents and their parents by the Impairment and Disability Study Group were includedin the DSM-5 field trial.
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World Health Organization Disability Assessment Schedule 2.0
世界衛(wèi)生組織殘疾評(píng)定量表
The adult self-administered version of the World Health Organization Disability AssessmentSchedule 2.0 (WHODAS 2.0) is a 36-item measure that assesses disability in adults age 18years and older. It assesses disability across six domains, including understanding andcommunicating, getting around, sel^care, getting along with people, life activities (i.e.,household, work, and/or school activities), and participation in society. If the adult individualis of impaired capacity and unable to complete the form (e.g., a patient with dementia),a knowledgeable informant may complete the proxy-administered version of themeasure, which is available at www.psychiatry.org/dsm5. Each item on the self-administeredversion of the WHODAS 2.0 asks the individual to rate how much difficulty he or she hashad in specific areas of functioning during the past 30 days.
WHODAS 2.0 Scoring Instructions Provided by WHO
WHODAS 2.0 summary scores. There are two basic options for computing the summaryscores for the WHODAS 2.0 36-item full version.
Simple: The scores assigned to each of the items—"none" (1), "mild" (2), "moderate" (3),"severe" (4), and "extreme" (5)—are summed. This method is referred to as simple scoringbecause the scores from each of the items are simply added up without recoding or collapsingof response categories; thus, there is no weighting of individual items. This approach ispractical to use as a hand-scoring approach, and may be the method of choice in busy clinicalsettings or in paper-and-pencil interview situations. As a result, the simple sum of thescores of the items across all domains constitutes a statistic that is sufficient to describe thedegree of functional limitations.
Complex: The more complex method of scoring is called "item-response-theory"(IRT)-based scoring. It takes into account multiple levels of difficulty for each WHODAS2.0 item. It takes the coding for each item response as "none," "mild," "moderate," "severe,"and "extreme" separately, and then uses a computer to determine the summaryscore by differentially weighting the items and the levels of severity. The computer programis available from the WHO Web site. The scoring has three steps:
• Step 1—Summing of recoded item scores within each domain.
• Step 2—Summing of all six domain scores.
• Step 3—Converting the summary score into a metric ranging from 0 to 100
(where 0=no disability; 100=full disability).WHODAS 2.0 domain scores. WHODAS 2.0 produces domain-specific scores for sixdifferent functioning domains: cognition, mobility, self-care, getting along, life activities(household and work/school), and participation.
WHODAS 2.0 population nomris. For the population norms for IRT-based scoring of theWHODAS 2.0 and for the population distribution of IRT-based scores for WHODAS 2.0,please seewww.who.int/classifications/icf/Pop_norms_distrib_IRT_scores.pdf.
Additional Scoring and interpretation Guidance forDSiVI-5 Users
The clinician is asked to review the individual's response on each item on the measureduring the clinical interview and to indicate the self-reported score for each item in the sectionprovided for "Clinician Use Only." However, if the clinician determines that the scoreon an item should be different based on the clinical interview and other information available, he or she may indicate a corrected score in the raw item score box. Based on findingsfrom the DSM-5 Field Trials in adult patient samples across six sites in the United Statesand one in Canada, DSM-5 recommends calculation and use of average scores for each domainand for general disability. The average scores are comparable to the WHODAS 5-point scale,which allows the clinician to think of the individual's disability in terms of none (1), mild(2), moderate (3), severe (4), or extreme (5). The average domain and general disabilityscores were found to be reliable, easy to use, and clinically useful to the clinicians in theDSM-5 Field Trials. The average domain score is calculated by dividing the raw domain scoreby the number of items in the domain (e.g., if all the items within the "understanding andcommunicating" domain are rated as being moderate then the average domain scorewould be 18/6=3, indicating moderate disability). The average general disability score is calculatedby dividing the raw overall score by number of items in the measure (i.e., 36). Theindividual should be encouraged to complete all of the items on the WHODAS 2.0. If no responseis given on 10 or more items of the measure (i.e., more than 25% of the 36 totalitems), calculation of the simple and average general disability scores may not be helpful.If 10 or more of the total items on the measure are missing but the items for some of the domainsare 75%-100% complete, the simple or average domain scores may be used for thosedomains.
Frequency of use. To track change in the individual's level of disability over time, themeasure may be completed at regular intervals as clinically indicated, depending on thestabihty of the individual's symptoms and treatment status. Consistently high scores on aparticular domain may indicate significant and problematic areas for the individual thatmight warrant further assessment and intervention.
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DSM5 中的WHDAS2.036項(xiàng)目版本, 由受檢者自評(píng)——————————————
微盤(pán)下載：http://vdisk.weibo.com/s/ud51QbvL-n9_/1402728421
WHO：http://www.who.int/classifications/icf/whodasii/en/
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