Funktionstillstånd och funktionshinder

Kunskapsläget för arbetsmetoder och insatser

Identifiering av vetenskaplig kunskap och kunskapsluckor utifrån systematiska översikter

Sammanfattning

Statens beredning för medicinsk och social utvärdering (SBU) har i uppdrag av regeringen att fastställa det vetenskapliga kunskapsläget inom området funktionstillstånd och funktionshinder. Som ett led i det har SBU genomfört en kartläggning av systematiska översikter (Faktaruta 1) som utvärderat insatser och arbetsmetoder inom området. Rapporten är en av sammanlagt fyra delrapporter som kartlägger kunskapsläget utifrån systematiska översikter inom funktionshinderområdet och socialtjänsten [1] [2] [3]. En kartläggning avser att ge en översiktlig bild av var det finns, eller saknas, vetenskaplig kunskap inom ett område och innehållet riktar sig framför allt till forskare och forskningsfinansiärer.

Syfte

Syftet med denna rapport är att kartlägga det vetenskapliga kunskapsläget inom funktionshinderområdet. Sammanställningen omfattar systematiska översikter om arbetsmetoder och insatser som genomförs eller skulle kunna genomföras med stöd av lagstiftningarna i Faktaruta 2.

De grupper som omfattas i kartläggningen är personer med funktionsnedsättning (psykisk, neuropsykiatrisk, intellektuell, sensorisk, fysisk med flera), anhöriga eller andra närstående till personer med funktionsnedsättning, samt yrkesverksamma inom funktionshinderområdet.

Bakgrund

Det finns ett flertal olika aktörer som arbetar med insatser inom funktionshinderområdet. Kommun, stat och regioner kartlägger, utreder, fattar beslut och utför, tillsammans med privata och ideella aktörer, insatser på daglig basis. Denna kartläggning gäller systematiska översikter om insatser och arbetsmetoder som genomförs eller skulle kunna genomföras av socialtjänsten (exempelvis personlig assistans, hemtjänst, daglig verksamhet) och andra kommunala förvaltningar (som handlägger exempelvis bostadsanpassning), samt statliga insatser som assistansersättning, bilstöd och särskild stödperson för introduktions- och uppföljningsstöd – SIUS (Faktaruta 2).

Avgränsning

Systematiska översikter som studerat arbetsmetoder och insatser inom hälso- och sjukvårdsområdet inklusive habilitering, rehabilitering, vardagstolkning och hjälpmedel, samt inom skola och utbildning liksom arbetslivsområdet och kriminalvård är exkluderade. Detsamma gäller systematiska översikter som inkluderar gruppen äldre (65+) med nedsättning av funktionsförmåga som enbart beror på åldrande, eller systematiska översikter som huvudsakligen omfattat personer med diagnoserna Alzheimers sjukdom och åldersrelaterad demens, liksom diagnoser som inte samtidigt innebär en funktionsnedsättning.

Vetenskaplig kunskap och vetenskapliga kunskapsluckor fastställs inte för insatser riktade till anhöriga eller andra närstående till personer med funktionsnedsättning. Detsamma gäller arbetsmetoder och arbetsverktyg som används av yrkesverksamma inom funktionshinderområdet. Detta beror på att litteratursökningen inte omfattat generellt riktade insatser eller arbetsmetoder till dessa grupper.

Vetenskaplig kunskap eller vetenskapliga kunskapsluckor fastställs inte heller för systematiska översikter vars resultat baseras på deskriptiva och kvalitativa data eller före- och efterstudier med en eller ett fåtal studiedeltagare.

I processen för en kartläggning ingår ingen prioritering av vetenskapliga kunskapsluckor som identifieras och kartläggningen syftar heller inte till att ge rekommendationer när det gäller användning eller implementering av insatser eller arbetsmetoder.

Metod

I en kartläggning fastställs kunskapsläget inom ett område genom att söka efter och identifiera systematiska översikter. Detta sker utifrån en bred frågeställning och från i förväg fastställda kriterier för inklusion och exklusion.

De systematiska översikter som identifieras och bedöms som relevanta för frågeställningen och inklusions-, samt exklusionskriterier presenteras i förhållande till fastställda områden. I denna kartläggning är det livs- och insatsområden. Med livsområden menas övergripande områden inom vilka insatser kan ges som påverkar en persons levnadsförhållanden. Insatsområden är övergripande områden som innefattar flera liknande insatser. För gruppen personer med funktionsnedsättning fastställdes 10 livsområden och 17 insatsområden. För anhöriga eller andra närstående till personer med funktionsnedsättning fastställdes två livsområden och därtill hörande insatsområden. De systematiska översikter som utvärderat arbetsmetoder och arbetsverktyg sorterades till kategorin yrkesverksamma. En och samma systematiska översikt kan omfatta flera livs- och insatsområden, liksom vara riktad till flera grupper. I kartläggningen kan därför samma systematiska översikt finnas sorterad inom flera områden och grupper.

För relevanta systematiska översikter som har medelhög eller hög metodologisk kvalitet bedöms det om det finns vetenskaplig kunskap eller om det är en vetenskaplig kunskapslucka. Detta för gruppen personer med funktionsnedsättning i förhållande till insatsområde. Enligt SBU identifieras en vetenskaplig kunskapslucka antingen när en systematisk översikt visar att det behövs mer praktiknära forskning, till exempel för att vi inte vet vilken effekt en insats har eller hur tillförlitlig en arbetsmetod är, eller när det saknas systematiska översikter av medelhög eller hög metodologisk kvalitet.

I det fall en vetenskaplig kunskapslucka konstateras ges information om vilken typ av forskning som behövs för att fylla kunskapsluckan. Detta kan vara en uppdatering av den systematiska översikten, en ny systematisk översikt, eller flera nya primärstudier.

Huvudresultat

Totalt har SBU identifierat 281 relevanta systematiska litteraturöversikter. 232 av dessa bedömdes hålla låg metodologisk kvalitet, 44 medelhög och 5 hög metodologisk kvalitet. Sammantaget identifierades därmed 49 systematiska litteraturöversikter med medelhög eller hög metodologisk kvalitet.

För gruppen personer med funktionsnedsättning finns relevanta systematiska översikter med medelhög eller hög metodologisk kvalitet inom alla tio livsområden. Flest antal systematiska översikter med medelhög eller hög metodologisk kvalitet finns inom livsområdena:

• Företa uppgifter samt hantera krav och egen aktivitetsnivå (36 systematiska översikter)
• Personlig vård, hälsa och välmående (29 systematiska översikter)
• Mellanmänskliga interaktioner och relationer (28 systematiska översikter).

För samma grupp finns det minsta antalet systematiska översikter inom livsområdena:

• Lärande och att tillämpa kunskap (8 systematiska översikter)
• Rörelse och förflyttning med hjälp av utrustning och transporthjälpmedel (9 systematiska översikter)
• Samhällsgemenskap, socialt samt medborgerligt liv och rättigheter (9 systematiska översikter).

För gruppen anhöriga eller närstående till personer med funktionsnedsättning finns relevanta systematiska översikter med medelhög eller hög metodologisk kvalitet identifierade inom två livsområden:

• Egen hälsa, välmående och fungerande (14 systematiska översikter)
• Föräldraförmåga/stödjande förmåga (11 systematiska översikter).

När det gäller gruppen yrkesverksamma identifierades en relevant systematisk översikt av medelhög eller hög metodologisk kvalitet. Den handlade om arbetsmetoder eller arbetsverktyg för att kartlägga, utreda, bedöma och fastställa tillstånd, fastställa behov av insats, fånga upplevelser erfarenheter eller fatta beslut om insatser för personer med funktionsnedsättning, och deras anhöriga eller andra närstående.

De flesta av de sammanlagt 49 systematiska översikterna med medelhög eller hög metodologisk kvalitet gäller grupperna neuropsykiatrisk funktionsnedsättning (24 systematiska översikter) samt anhöriga eller andra närstående till personer med funktionsnedsättning (21 systematiska översikter). Därefter följer intellektuell funktionsnedsättning (11 systematiska översikter) samt psykisk funktionsnedsättning (8 systematiska översikter). För gruppen fysisk funktionsnedsättning finns det färre systematiska översikter med medelhög eller hög metodologisk kvalitet (5 systematiska översikter). För grupperna dyslexi, dyskalkyli, språknedsättning, flerfunktionsnedsättning och sensorisk funktionsnedsättning saknas systematiska översikter med medelhög eller hög metodologisk kvalitet helt.

Vetenskaplig kunskap identifierades för gruppen:

• Neuropsykiatrisk funktionsnedsättning inom 8 av 17 insatsområden.
• Psykisk funktionsnedsättning inom 4 av 17 insatsområden.
• Intellektuell funktionsnedsättning inom 4 av 17 insatsområden.
• Fysisk funktionsnedsättning inom 2 av 17 insatsområden.

Vetenskapliga kunskapsluckor identifierades för gruppen:

• Psykisk funktionsnedsättning inom 13 av 17 insatsområden.
• Neuropsykiatrisk funktionsnedsättning inom 9 av 17 insatsområden.
• Intellektuell funktionsnedsättning inom 13 av 17 insatsområden.
• Fysisk funktionsnedsättning inom 15 av 17 insatsområden.

Då det helt saknades systematiska översikter av medelhög eller hög kvalitet inom alla insatsområden för grupperna sensorisk funktionsnedsättning, dyslexi, dyskalkyli, språknedsättning, samt flerfunktionsnedsättning föreligger det enligt SBU:s definition vetenskapliga kunskapsluckor inom alla 17 insatsområden.

De insatsområden där flest vetenskapliga kunskapsluckor påträffades för de flesta funktionsnedsättningsgrupperna var:

• Autonomirelaterade insatser
• Boenderelaterade insatser
• Föräldraförmågafrämjande insatser
• Motivationsinriktade insatser
• Transportrelaterade insatser

1. Inledning

Statens beredning för medicinsk och social utvärdering (SBU) har i uppdrag av regeringen att fastställa det vetenskapliga kunskapsläget inom området funktionstillstånd och funktionshinder. Som ett led i det har SBU genomfört en kartläggning av systematiska översikter som utvärderat insatser och arbetsmetoder inom området. Rapporten är en av sammanlagt fyra delrapporter som kartlägger kunskapsläget utifrån systematiska översikter inom funktionshinderområdet och socialtjänsten [1] [2] [3].

1.1 Syfte

Syftet med denna rapport är att kartlägga det vetenskapliga kunskapsläget inom funktionshinderområdet. Detta genom att identifiera och kartlägga:

• Inom vilka livs- och insatsområden samt för vilka funktionsnedsättningsgrupper det finns systematiska översikter som utvärderat insatser inom funktionshinderområdet.
• Systematiska översikter som utvärderat insatser riktade till anhöriga eller andra närstående till personer med funktionsnedsättning.
• Systematiska översikter som utvärderat arbetsmetoder och arbetsverktyg som kan användas av yrkesverksamma som arbetar inom funktionshinderområdet.
• Inom vilka insatsområden och för vilka funktionsnedsättningsgrupper det finns vetenskaplig kunskap eller vetenskapliga kunskapsluckor.

Kartläggningen omfattar insatser eller arbetsmetoder som utförs och används, eller skulle kunna utföras och användas, med stöd av de lagstiftningar som finns presenterade i Faktaruta 1.2. Sådana insatser eller arbetsmetoder utförs inom ramen för kommuners socialtjänst, andra berörda kommunala förvaltningar, liksom privata aktörers, och statliga myndigheters arbete.

1.2 Rapportens målgrupp

Rapporten är skriven framför allt för forskare och forskningsfinansiärer.

2. Bakgrund

2.1 Utgångspunkter

Utgångspunkter i arbete med utvärdering och kartläggning inom område funktionstillstånd och funktionshinder är:

• FN:s konvention om rättigheter för personer med funktionsnedsättning.
• De nationella funktionshinderpolitiska målen.
• Den internationella klassifikationen av funktionstillstånd, funktionshinder och hälsa (International Classification of Functioning, Disability and Health, ICF).
• Socialstyrelsens definitioner inom området.

FN:s konvention om rättigheter för personer med funktionsnedsättning fokuserar på icke-diskriminering och dess syfte är att undanröja hinder för personer med funktionsnedsättning att åtnjuta sina mänskliga rättigheter [54] [55]. Förutsättningar för självständighet och självbestämmande ska skapas, hinder för delaktighet i samhället ska identifieras samt undanröjas och diskriminering ska förebyggas och motverkas. De funktionshinderpolitiska målsättningarna, som bygger på FN:s konvention om rättigheter för personer med funktionsnedsättning, handlar om att uppnå jämlikhet i levnadsvillkor och full delaktighet i samhället för personer med funktionsnedsättning [56].

Klassifikation av funktionstillstånd, funktionshinder och hälsa (ICF) [57] är en av Världshälsoorganisationens (WHO) huvudklassifikationer. Klassifikationen erbjuder en struktur och standardiserat språk som är tänkt att användas över kulturella gränser för att beskriva funktionstillstånd, funktionshinder och hälsa. Socialstyrelsen rekommenderar sedan år 2017 att den används för alla åldrar [58].

2.1.1 Definitioner och begrepp

Enligt Socialstyrelsens termbank definieras funktionsnedsättning som en nedsättning av funktionsförmåga, medan funktionshinder speglar den begränsning en funktionsnedsättning kan utgöra i relation till den omgivning och miljö personen befinner sig [59]. Begreppen funktionsvariation eller funktionsskillnader används utifrån betydelsen att de ska uppfattas mer neutrala och betona att alla människor fungerar på olika sätt, inte bättre eller sämre [60]. Dessa begrepp finns dock inte med i Socialstyrelsens termbank, vilken SBU utgår ifrån. Funktionstillstånd är det begrepp som finns beskrivet i termbanken och avser att på ett neutralt sätt spegla tillståndet hos en persons psykiska och fysiska kroppsfunktioner och kroppsstrukturer. Funktionstillstånd och funktionshinder används som paraplytermer i ICF och de betecknar positiva och negativa aspekter av ett funktionstillstånd [61] [62]. Funktionshinder är paraplytermen för funktionsnedsättningar, strukturavvikelser, aktivitetsbegränsningar och delaktighetsinskränkningar.

2.2 Arbetsmetoder och insatser inom område funktionstillstånd och funktionshinder

Det finns ett flertal olika aktörer som arbetar med insatser inom funktionshinderområdet. Kommun, stat och regioner kartlägger, utreder, fattar beslut och utför, tillsammans med privata och ideella aktörer, insatser på daglig basis. Flera myndigheter arbetar med att ta fram kunskap, kunskapsstöd och vägledningar inom området. Någon samlad bild av vilka arbetsmetoder för kartläggning, utredning och beslutsfattande som används är svår att nå med den mångfald av aktörer och insatser som finns inom funktionshinderområdet.

Insatser går tydligare att urskilja då ett flertal av dessa regleras i lagstiftning. I Bilaga 1 finns exempel på lagstiftningar och andra rättsdokument som berör funktionshinderområdet. I Bilaga 2 finns exempel på insatser som är riktade till personer med funktionsnedsättning samt beskrivning av vilken lagstiftning som reglerar dem. Det finns även motsvarande för anhöriga eller andra närstående till personer med funktionsnedsättning, samt exempel på arbetsmetoder som används av yrkesverksamma inom funktionshinderområdet. Beskrivningarna är inte tänkta att vara fullständiga och alla exemplen är inte inkluderade i denna kartläggning.

2.3 Hur många och vilka berörs

Det finns inga officiella kriterier i Sverige för att fastställa vilka som ingår i gruppen personer med funktionsnedsättning och myndigheter och aktörer använder olika definitioner [63]. Enligt Socialstyrelsen innefattar gruppen personer med nedsättning av fysisk, psykisk eller intellektuell funktionsförmåga [59]. SBU beskriver med utgångspunkt från denna definition gruppen personer med funktionsnedsättning till att omfatta:

• Psykisk funktionsnedsättning
• Neuropsykiatrisk funktionsnedsättning
• Intellektuell funktionsnedsättning
• Sensorisk funktionsnedsättning
• Fysisk funktionsnedsättning
• Andra funktionsnedsättningar såsom dyslexi, dyskalkyli, tal/språkstörning
• Flerfunktionsnedsättning

Olika funktionsnedsättningar kan kopplas till sjukdomsdiagnoser [64] och funktionstillstånd [61], vilket beskrivs i Bilaga 3. Med flerfunktionsnedsättning avses en kombination av mycket svår intellektuell funktionsnedsättning och omfattande neuromuskuloskeletal eller rörelserelaterad funktionsnedsättning. Ovanstående och beskrivningarna i Bilaga 3 har varit utgångspunkt i denna kartläggning.

När det gäller antalet personer som har en funktionsnedsättning i Sverige varierar uppskattningarna mellan myndigheter och mättillfälle. Enligt Statistiska Centralbyrån uppgav cirka 15 procent av befolkningen år 2015–2016 att de hade en funktionsnedsättning, vilket motsvarade cirka 900 000 personer [65]. Folkhälsomyndighetens nationella folkhälsoenkät för år 2018 rapporterade att andelen personer 16–84 år som uppgav att de hade en funktionsnedsättning motsvarade cirka 22 procent [66]. Vi de senaste undersökningarna av levnadsförhållanden (ULF/SILC 2016-2017) som Statistiska centralbyrån gjort bedömdes 29,5 procent av befolkningen tillhöra gruppen personer med funktionsnedsättning (16–64 år) (SCB) [67]. De grupper som omfattades var personer med:

• Synsvårigheter (3,5 %)
• Hörselnedsättning (11,8 %)
• Nedsatt rörelseförmåga (2,6 %)
• Svåra besvär av astma och/eller allergi (7,4 %)
• Svåra besvär av ängslan, oro eller ångest (8,1 %)
• I hög grad nedsatt aktivitetsförmåga (3,2 %)
• Stora problem på grund av dyslexi och/eller dyskalkyli (uppgift inte redovisad av SCB)
• Neuropsykiatrisk diagnos (3,0 %)

Andelen personer som har intellektuell funktionsnedsättning uppskattas till att vara cirka 1 procent av befolkningen [68]. Föräldrar till barn (7–18 år) med funktionsnedsättning skattades för år 2016 till att vara 5,5 procent [67].

När det gäller antalet personer med funktionsnedsättning som får insatser med stöd av lagstiftningar finns mer precis statistik.

Antalet personer som år 2018 tog emot kommunala insatser enligt Lag om stöd och service för vissa funktionshindrade (LSS) var cirka 74 000 [69]. Fördelningen mellan insatserna presenteras i Tabell 2.1.

De största kommunala insatserna enligt LSS är daglig verksamhet och vuxenboende. Insatsen råd och stöd minskade med 29 procent mellan åren 2017 och 2018, då insatsen numera huvudsakligen ges inom ramen för Hälso- och sjukvårdslagen (HSL) [70].

Personlig assistans som kommunal insats enligt LSS ökade mellan åren 2009 och 2018 från 3 400 till 5 100 personer [70]. Den statliga assistansersättningen som betalas ut för personlig assistans i enlighet med Socialförsäkringsbalken omfattade 16 142 personer år 2015 och år 2018 var motsvarande siffra 14 508. I de fall assistansersättning enligt Socialförsäkringsbalken dras in får många istället stöd från kommunen huvudsakligen i form av hemtjänst, bostad med särskild service och personlig assistans enligt LSS [71].

Drygt 52 000 personer med funktionsnedsättning i åldrarna 0-64 år hade år 2015 insatser enligt Socialtjänstlagen (SoL). Tillsammans hade de cirka 71 300 insatser. Samma siffror fram till den 31 oktober år 2018 var ca 55 800 personer och 68 800 insatser [72]. I Tabell 2.2 presenteras antal personer 0-64 år med pågående insats enligt SoL fram till den 31 oktober år 2015 [71].

3. Metod

I en kartläggning fastställs kunskapsläget inom ett område genom att söka efter (litteratursökning) och identifiera relevanta systematiska översikter. Det sker utifrån en bred frågeställning samt kriterier enligt vilka systematiska översikter ska bedömas avseende relevans. Dessa benämns inklusions- och exklusionskriterier. De systematiska översikternas metodologiska kvalitet bedöms därefter.

Systematiska översikter som identifieras och bedöms som relevanta för frågeställningen och kriterierna sorteras sedan utifrån sitt innehåll till ett eller flera livs- och insatsområden. Dessa områden utformas av sakkunniga i projektet. Resultaten från flera systematiska översikter slås inte ihop eller bedöms i relation till varandra.

För de systematiska översikter som bedöms som relevanta samt med medelhög eller hög metodologisk kvalitet fastställs därefter om det finns vetenskaplig kunskap eller om det är en vetenskaplig kunskapslucka. I denna kartläggning görs det för gruppen personer med funktionsnedsättning per insatsområde.

Enligt SBU identifieras en vetenskaplig kunskapslucka när:

• En systematisk översikt visar att det behövs mer praktiknära forskning, till exempel för att vi inte vet vilken effekt en insats har eller hur tillförlitlig en arbetsmetod är.
• Det saknas systematiska översikter av medelhög eller hög metodologisk kvalitet.

I det fall en vetenskaplig kunskapslucka konstateras ges information om vilken typ av forskning som behövs för att fylla kunskapsluckan. Det kan ske genom en uppdatering av den systematiska översikten, en ny systematisk översikt, eller flera nya primärstudier.

3.1 Särskilda avgränsningar

Arbetet i denna kartläggning har skett i två steg. Litteratursökningen¹ och därpå följande abstraktgranskning baserades på den projektplan [53] som fastställdes vid start. Litteratursökning och abstraktgranskning bedömdes omfatta de lagstiftningar som beskrivs i Faktaruta 1.2 (också Bilaga 1). Innehållet i projektplanen anpassades därefter i förhållande till förutsättningar som bedömdes relevanta för funktionshinderområdet. Syften och frågeställningar utvecklades och kriterier för exklusion utökades. De så kallade domäner som identifierats i projektplanen bedömdes inte som tillräckligt omfattande för funktionshinderområdet utan nya utformades som benämndes livsområden. Med livsområden menas övergripande områden inom vilka insatser som kan ges som påverkar en persons levnadsförhållanden. Det finns ett stort antal insatser inom funktionshinderområdet (Bilaga 2), och liknande insatser har i denna kartläggning sammanfattats till bredare insatsområden. Insatser kan vidare vara riktade till olika grupper och de grupper som omfattas i kartläggningen är personer med funktionsnedsättning (Bilaga 3) anhöriga eller andra närstående till personer med funktionsnedsättning, samt yrkesverksamma inom funktionshinderområdet. Systematiska översikter som utvärderat arbetsmetoder och arbetsverktyg sorterades till gruppen yrkesverksamma.

^1. Litteratursökningen baserades på populationsbeskrivningen: Utvecklingsstörning/begåvningsmässig funktionsnedsättning, Neuropsykiatriska funktionsnedsättningar, Varaktiga fysiska eller psykiska funktionsnedsättningar som inte beror på normalt åldrande, inga begränsningar gällande samsjuklighet, ålder eller kön.

3.2 Frågeställningar

• Inom vilka livs- och insatsområden finns det relevanta systematiska översikter avseende insatser till personer med funktionsnedsättning?
• Inom vilka livsområden finns det relevanta systematiska översikter avseende insatser till anhöriga eller andra närstående till personer med funktionsnedsättning?
• Finns det relevanta systematiska översikter som utvärderat arbetsmetoder och arbetsverktyg som kan användas av yrkesverksamma inom funktionshinderområdet?
• För vilka systematiska översikter av medelhög eller hög metodologisk kvalitet och inom vilka insatsområden finns det vetenskaplig kunskap respektive vetenskapliga kunskapsluckor när det gäller gruppen personer med funktionsnedsättning?

3.3 Litteratursökning

Litteratursökningen genomfördes i databaserna Academic Search Elite, ERIC, PsycInfo, SocIndex (via EBSCO), Medline (OVID), Cochrane Libray (Wiley), Applied Social Sciences Index and Abstracts (ASSIA), Sociological Abstracts/Social Services Abstracts, International Bibliography of Social Sciences (IBSS) (via Proquest), Scopus (via Elsevier) och Social Care online (endast utvalda referenser sparades ner). I Bilaga 4 framgår litteratursökningen i sin helhet.

Sökningarna gjordes under våren år 2017 och innehöll sökord (kontrollerad vokabulär och fritext) för populationen. Sökningen avgränsades till studietyperna systematiska översikter, metaanalyser eller metasynteser som publicerats år 2000 eller senare. Vidare avgränsades sökningen till språken engelska, svenska, norska och danska.

Litteratursökningen omfattade inte litteratur om omgivande faktorer såsom exempelvis attityder, och inte heller litteratur som generellt studerar insatser riktade till anhöriga eller andra närstående eller generella arbetsmetoder för yrkesverksamma. Inte heller omfattades universella insatser av funktionshinderreducerande karaktär [56].

3.4 Inklusions- och exklusionskriterier

Identifierad litteratur bedömdes avseende relevans i enlighet med nedanstående inklusions- och exklusionskriterier.

3.4.1 Inklusionskriterier

3.4.1.1 Studiedesign, tidsomfattning och språk

Systematiska översikter skrivna på engelska, svenska, norska eller danska och publicerade i vetenskapliga peer-reviewed tidskrifter från år 2000 fram till juni år 2017 är inkluderade.

De systematiska översikterna kan ha innehållit enbart primärstudier, eller primärstudier samt andra systematiska översikter. Inga avgränsningar har gjorts avseende studiedesign hos de studier som är inkluderade i de systematiska översikterna.

3.4.1.2 Kontext

Arbetsmetoder och insatser som utförs, eller skulle kunna utföras med stöd av de lagstiftningar som finns presenterade i Faktaruta 1.2, och ges inom ramen för kommuners socialtjänst, andra berörda kommunala förvaltningar, liksom privata aktörers (t.ex. privata utförare av personlig assistans och hemtjänst) och statliga myndigheters arbete är inkluderade. De statliga myndigheterna är till exempel Socialstyrelsen, Myndigheten för delaktighet, Försäkringskassan, Arbetsförmedlingen och Boverket.

Systematiska översikter inkluderades där studier av insatser eller arbetsmetoder varit förlagda till samhället, hemmet, eller inom ramen för kommuners socialtjänst, andra berörda kommunala förvaltningar, liksom privata aktörers och statliga myndigheters arbete.

Systematiska översikter baserade på studier genomförda inom ovanstående kontext samt inom utbildning, vård, habilitering och rehabilitering samt i arbetslivet, inkluderades om de sistnämnda stod för mindre än hälften av underlaget.

3.4.1.3 Population

De populationer som har inkluderats är:

• Personer i alla åldrar med psykiska, neuropsykiatriska, intellektuella, sensoriska, fysiska funktionsnedsättningar samt dyslexi, dyskalkyli och språkstörning liksom flerfunktionsnedsättning.
• Anhöriga eller andra närstående till personer med funktionsnedsättning. Som anhöriga räknas föräldrar eller vårdnadshavare till barn med funktionsnedsättning, barn till föräldrar med funktionsnedsättning, syskon till barn med funktionsnedsättning, make/maka/partner till person med funktionsnedsättning, andra närstående till person med funktionsnedsättning.
• Yrkesverksamma som arbetar med stöd samt utredning och beslut om insatser inom funktionshinderområdet där arbetsmetoden eller insatsen utförs, eller skulle kunna utföras inom ramen för kommuners socialtjänst, övriga berörda kommunala förvaltningar liksom privata aktörers och statliga myndigheters arbete.

3.4.1.4 Insatser

Vi har inkluderat systematiska översikter som studerat arbetsmetoder och insatser som skulle kunna tillhandahållas i ett svenskt perspektiv med stöd av lagstiftningarna i Faktaruta 1.2. I Bilaga 5 beskrivs de insatser som är inkluderade utifrån insatsområde.

3.4.1.5 Jämförelseinsats

Inga begräsningar har gjorts vad gäller jämförelseinsatser. En jämförelseinsats kan exempelvis vara ingen insats eller en annan likvärdig insats.

3.4.1.6 Utfall

Utifrån de utgångspunkter som finns beskrivna i Kapitel 2.1 samt målsättningar och insatsinnehåll i lagstiftningarna har följande utfall bedömts som relevanta:

• Tillförlitlighet/validitet
• Användbarhet
• Anhörigas eller andra närståendes välmående och hälsa
• Anhörigas eller andra närståendes föräldraförmåga/stödjande förmåga
• Jämlikhet i livsvillkor
• Leva ett liv som andra
• Deltagande i samhällslivet
• Delaktighet/Delaktighetsinskränkning
• Aktivitet/Aktivitetsbegränsning
• Mångfald
• Livskvalitet
• Nöjdhet/Tillfredsställelse
• Hälsa
• Nytta
• Självständighet/Självbestämmande
• Beteende
• Psykosociala utfall (stress, ångest, depression)
• Förebygga/Bekämpa diskriminering
• Rättvisa
• Likvärdighet i insatsinnehåll
• Likvärdighet i behovsbedömning/beslutsbedömning
• Insatskvalitet
• Hur bra är en behandling eller insats?
• Hur bedöms behoven på bästa sätt?
• Hur ska resurser användas för att göra största möjliga nytta?
• Sidoeffekter, oönskade händelser, problem, svårigheter eller händelser i samband med metod eller insats
• Beskrivning av upplevelser eller erfarenheter av insatser, arbetsmetoder, funktionsnedsättning eller funktionshinder

3.4.2 Exklusionskriterier

3.4.2.1 Studiedesign

Översikter som inte varit systematiska översikter är exkluderade. Detta gäller exempelvis scoping reviews, översikt av översikter (review of reviews) samt översikter (reviews) som inte presenterat en tydlig metod i förhållande till SBU:s kriterier (Faktaruta 1.1). Systematiska översikter som haft ett deskriptivt syfte har exkluderats, liksom primärstudier.

3.4.2.2 Kontext

De systematiska översikter som inkluderat studier som är genomförda helt och hållet, eller till mer än hälften inom vård, habilitering, rehabilitering, kriminalvård, i arbetsliv, och utbildningsväsendet är exkluderade.

3.4.2.3 Population

Systematiska översikter som baserats på studier som studerat äldre (65+) personer vars nedsättning av funktionsförmåga enbart beror på åldrande har exkluderats. Detsamma gäller systematiska översikter som studerat insatser riktade till personer med diagnoserna Alzheimers sjukdom, åldersrelaterad demens, liksom diagnoser som inte samtidigt innebär en funktionsnedsättning. Systematiska översikter som studerat behandlingar riktade till personer med diagnoserna stroke, depression, förvärvad hjärnskada är exkluderade då sådan behandling huvudsakligen tillhör hälso- och sjukvårdens ansvarsområden. Undantagna är systematiska översikter som handlat om insatser för personer med dessa diagnoser som genomförts inom ramen för de lagstiftningar som beskrivs i Faktaruta 1.2, de är inkluderade.

3.4.2.4 Insatser

Systematiska översikter som studerat arbetsmetoder och insatser inom hälso- och sjukvårdsområdet inklusive habilitering, rehabilitering och hjälpmedel, samt skola och utbildning liksom arbetslivsområdet och kriminalvård är exkluderade. Detsamma gäller systematiska översikter som studerat allmänna och universella insatser. Sådana kan handla om så kallad universell utformning av produkter och miljö, allmänna krav på och insatser i bostäder och byggd miljö, allmänna krav på tillgängliga transporter, liksom allmänna delaktighetsfrämjande insatser (exempelvis lättläst material och talböcker). I Bilaga 6 finns en sammanställning av de insatser och arbetsmetoder som exkluderats.

3.5 Bedömning av relevans av systematiska översikter

För att en systematisk översikt ska anses relevant och inkluderas måste följande krav vara uppfyllda:

• Inklusions- och exklusionskriterier är angivna.
• Systematiska översikten studerar arbetsmetoder och insatser som skulle kunna tillhandahållas i en svensk kontext med stöd av de inkluderade lagstiftningarna (Faktaruta 1.2).

Urvalet av relevanta systematiska översikter sker i två steg:

• Urval efter bedömning av relevans vid genomläsning av sammanfattning (abstrakt).
• Urval och relevansbedömning efter att ha lästs i fulltext.

Steg 1, granskning av artiklarnas sammanfattning gjordes av två projektledare på SBU oberoende av varandra. De abstrakt som minst en av de två projektledarna ansåg skulle inkluderas gick vidare för läsning i fulltext.

Steg två, relevansbedömning genom läsning i fulltext av artiklarna, genomfördes parvis, oberoende av varandra, av projektgruppens medlemmar. Vid oenighet om inklusion fördes först en diskussion inom paret och vid behov involverades hela projektgruppen i diskussionen och beslut togs i konsensus.

3.6 Bedömning av kvalitet i systematiska översikter

De systematiska översikternas vetenskapliga kvalitet, det vill säga hur metodologiskt välgjorda de var, bedömdes på övergripande nivå med stöd av AMSTAR granskningsmall (Bilaga 7) [73] [74]. Kvalitet i de studier som var inkluderade i respektive systematisk översikt bedömdes inte.

För att en systematisk översikt skulle bedömas vara av medelhög metodologisk kvalitet skulle den minst uppfylla punkterna 1–4 nedan. För att bedömas ha hög metodologisk kvalitet skulle alla punkterna (1–6) nedan vara uppfyllda. Övriga bedömdes hålla låg metodologisk kvalitet.

1. Frågeställningen är tydligt definierad i enlighet med PICO/SPICE² eller liknande, inklusion- och exklusionskriterier är angivna, och litteratursökningen matchar frågeställningen samt är väl genomförd och dokumenterad så att den kan återskapas (AMSTAR fråga 1 och 3).
2. Studiernas relevans har granskats av två oberoende personer på abstrakt och fulltextnivå och de inkluderade studierna finns angivna (AMSTAR fråga 2 och 5).
3. Inkluderade studier är kvalitetsgranskade på ett rimligt sätt. Det är transparent hur olika kvalitetsnivåer är satta, det vill säga kriterier för kvalitetsnivå ska finnas beskrivna. Kvalitet, karakteristika och resultat på de respektive inkluderade studierna framgår tydligt och finns dokumenterade (AMSTAR fråga 6 och 7).
4. Studierna har vägts samman i metaanalys eller metasyntes på ett korrekt sätt om det ansetts vara lämpligt, i annat fall har de beskrivits narrativt (AMSTAR fråga 9).
5. Resultaten är evidensgraderade eller beskrivna i slutsatsen, där hänsyn har tagits till studiernas kvalitet och rimlig hänsyn tagits till överförbarhet, samstämmighet, precision och risk för publikationsbias (AMSTAR fråga 8 och 10).
6. Exkluderade studier finns dokumenterade, likaså författarnas jävsförhållanden samt hur eventuella jävsförhållanden hanterats. Protokoll för översikten finns och författarna har angett om alla typer av publikationer omfattades av litteratursökningen eller inte. Författarna har beskrivit ett konsensusförfarande för när granskare har bedömt studierna olika (AMSTAR fråga 1,2, 4, 5 och 11) [73 [74].

Kvalitetsgranskningen genomfördes av projektgruppen och samtliga systematiska översikter granskades av minst två personer oberoende av varandra. Oenigheter löstes genom diskussion och en tredje person inom projektgruppen rådfrågades vid behov.

^2. PICO är en förkortning för Population, Intervention (sv. insats), Control (sv. jämförelseinsats, Outcome (sv. utfall). SPICE är en förkortning av Setting (sv. kontext), Perspective (sv. perspektiv), Intervention (sv. insats), Comparison (sv. jämförelse), Evaluation (sv. utvärdering).

3.7 Fördelning av systematiska översikter till livs- och insatsområden

De systematiska översikter som identifierades och bedömdes som relevanta för frågeställningen och uppfyllde inklusions- samt exklusionskriterier, liksom var av medelhög eller hög metodologisk kvalitet fördelades i relation till på förhand fastställda livsområden samt identifierade insatsområden. Med livsområden avses som tidigare nämnt övergripande områden inom vilka insatser kan ges som påverkar en persons levnadsförhållanden, medan enskilda insatser sammanförts inom bredare sammanfattande insatsområden. En och samma översikt kan bedömas tillhöra mer än ett livs- eller insatsområde.

3.7.1 Livsområden

Livsområdena i denna rapport utformades av kartläggningens externa sakkunniga och projektledare. Utgångspunkten var att identifiera livsområden som speglar bredden i kartläggningens syften och frågeställningar och som omfattar hela funktionshinderområdet.

I WHO:s klassifikation av funktionstillstånd, funktionshinder och hälsa (ICF) finns nio så kallade domäner och fem omgivningsfaktorer utformade [61]. I Bilaga 9 finns en beskrivning av dem. Domänerna är individinriktade och avser att täcka det fullständiga omfånget av områden inom vilka en person är aktiv och delaktig [61]. Omgivningsfaktorerna utgör den fysiska, sociala och attitydmässiga omgivning i vilken människor lever och verkar [61], och speglar den roll som omgivningen har för uppkomst av funktionshinder [62]. Domänerna har utgjort underlag för de livsområden som identifierats som relevanta för personer med funktionsnedsättning i denna kartläggning. Även omgivningsfaktorerna är relevanta som livsområden i en kartläggning avseende funktionshinderområdet. Litteratursökningen i föreliggande kartläggning var utformad att identifiera litteratur om arbetsmetoder samt insatser riktade till individen, och inte litteratur om omgivande faktorer. Därför har fyra av de fem omgivningsfaktorerna i ICF inte bedömts vara relevanta som livsområden i föreliggande kartläggning. Omgivningsfaktorn personligt stöd och personliga relationer har bedömts som relevant livsområde eftersom litteratursökningen omfattat litteratur om anhöriga eller andra närstående till personer med funktionsnedsättning samt yrkesverksamma. I personligt stöd och personliga relationer beskrivs det stöd som anhöriga, andra närstående och yrkesverksamma kan utgöra till en person med funktionsnedsättning.

Livsområdena för anhöriga eller andra närstående till personer med funktionsnedsättning, utgick från det förslag som togs fram i enlighet med ursprunglig projektplan³, men delades upp i två områden och formulerades om i viss utsträckning.

När det gäller arbetsmetoder och arbetsverktyg för att kartlägga, utreda, bedöma och fastställa tillstånd, fastställa behov av insats, fånga upplevelser erfarenheter eller fatta beslut om insatser för personer med funktionsnedsättning, och deras anhöriga eller andra närstående sorteras det till gruppen yrkesverksamma inom funktionshinderområdet.

^3. Yrkesverksamma: Behovsbedömning, särskilt stöd vid utredning, behovsbedömning anhöriga, uppföljning av behov, insatser eller aktiviteter. Anhöriga till personer med funktionsnedsättning: Anhörigstöd och familjeorienterat arbete, direkt stöd och indirekt stöd

3.7.1.1 Identifierade livsområden

Totalt identifierades tio livsområden för personer med funktionsnedsättning, två livsområden för anhöriga eller andra närstående till personer med funktionsnedsättning och ett område för gruppen yrkesverksamma. Benämningarna på livsområdena för personer med funktionsnedsättning följer huvudsakligen ICF:s språk, men har kompletterats i vissa fall för att ytterligare tydliggöra innehållet.

Personer med funktionsnedsättning:

1. Lärande och att tillämpa kunskap
2. Företa uppgifter samt hantera krav och egen aktivitetsnivå
3. Språk, kommunikation och information
4. Rörelse och förflyttning med hjälp av utrustning och transporthjälpmedel
5. Personlig vård, hälsa och välmående
6. Boende, hushåll och hemliv
7. Mellanmänskliga interaktioner och relationer
8. Utbildning, arbete och sysselsättning samt ekonomi och försörjning
9. Samhällsgemenskap, socialt samt medborgerligt liv och rättigheter
10. Personligt stöd och personliga relationer.

Anhöriga eller andra närstående till personer med funktionsnedsättning:

1. Egen hälsa, välmående och fungerande
2. Föräldraförmåga/stödjande förmåga.

Yrkesverksamma inom funktionshinderområdet:

1. Arbetsmetoder/arbetsverktyg för att kartlägga, utreda, bedöma och fastställa tillstånd, fastställa behov av insats, fånga upplevelser erfarenheter eller fatta beslut om insatser för personer med funktionsnedsättning, och deras anhöriga eller andra närstående.

3.7.2 Identifierade insatsområden

Totalt identifierades 17 insatsområden baserade på de insatser som beskrivs i lagstiftningarna i Faktaruta 1.2 samt de insatser som identifierades i de inkluderade systematiska översikterna:

• Arbets-, sysselsättnings- och fritidsinriktade insatser
• Autonomirelaterade insatser
• Beteendeinriktade insatser
• Boenderelaterade insatser
• Delaktighetsfrämjande och socialt främjande insatser
• Fysiska insatser
• Föräldraförmågafrämjande insatser
• Kognitiva insatser
• Kommunikationsinriktade insatser
• Motivationsinriktade insatser
• Pedagogiska insatser
• Personlig assistans
• Psykosociala insatser
• Sensoriska insatser
• Stöd från anhöriga/föräldrar/vänner/andra
• Transportrelaterade insatser
• Andra hälsorelaterade insatser

De enskilda insatserna inom varje insatsområde finns beskrivna i Bilaga 5.

3.8 Vetenskaplig kunskap och vetenskapliga kunskapsluckor

Därefter bedömdes det om det fanns vetenskaplig kunskap eller vetenskapliga kunskapsluckor. Enligt SBU identifieras en vetenskaplig kunskapslucka när:

• En systematisk översikt av medelhög eller hög metodologisk kvalitet visar att det behövs mer praktiknära forskning, till exempel för att vi inte vet vilken effekt en insats har eller hur tillförlitlig en arbetsmetod är.
• Det saknas systematiska översikter av medelhög eller hög metodologisk kvalitet.

I det fall en vetenskaplig kunskapslucka konstateras gjordes en rekommendation om åtgärd för att fylla luckan. Det kan ske genom att göra:

• En uppdatering av den systematiska översikten
• En ny systematisk översikt
• Flera nya primärstudier.

Bedömningen om det föreligger vetenskaplig kunskap eller vetenskaplig kunskapslucka gjordes för gruppen personer med funktionsnedsättning per insatsområde. För systematiska översikter som handlar om insatser riktade till anhöriga eller andra närstående till personer med funktionsnedsättning, samt arbetsmetoder som används av yrkesverksamma inom funktionshinderområdet fastställdes inte vetenskaplig kunskap eller vetenskapliga kunskapsluckor. Detsamma gäller systematiska översikter vars resultat är baserat på kvalitativa data, eller primärstudier med en före- och efterdesign med en eller ett fåtal undersökningspersoner.

I ett första steg bedömdes om det föreligger vetenskaplig kunskap eller vetenskaplig kunskapslucka för de insatser som utvärderats i respektive inkluderad systematisk översikt av medelhög eller hög metodologisk kvalitet. Bedömningen baserades på de slutsatser författarna av den systematiska översikten dragit. För systematiska översikter som utvärderat flera insatser och omfattat flera funktions­nedsätt­nings­grupper kan bedömningen vara att det föreligger både vetenskaplig kunskap och vetenskaplig kunskapslucka. När vetenskaplig kunskap konstaterades baserat på resultat där litteratursökning var äldre än 2014 rekommenderas i denna kartläggning en uppdatering av den systematiska översikten.

I steg två konstaterades vetenskapliga kunskapsluckor för de insatsområden där inga systematiska översikter av medelhög eller hög metodologisk kvalitet har identifierats. Då det saknas en systematisk översikt av medelhög eller hög metodologisk kvalitet är det enligt SBU:s definition en vetenskaplig kunskapslucka. Denna kartläggnings bredd och omfattning innebär att insatsområden, eller delar av dem, kan vara relevanta för alla funktionsnedsättningsgrupper medan andra huvudsakligen kan vara utformade för, eller riktade till, vissa specifika funktionsnedsättningsgrupper. Kartläggningens resultat när det gäller vetenskapliga kunskapsluckor måste därför kompletteras med bedömning utifrån specifik sakkompetens för att säkert fastställa i vilken utsträckning ett insatsområde utgör en vetenskaplig kunskapslucka för en specifik funktionsnedsättningsgrupp.

I processen för denna kartläggning ingår ingen prioritering av de vetenskapliga kunskapsluckor som identifieras. Den syftar heller inte till att ge rekommendationer när det gäller användning eller implementering av arbetsmetoder och insatser.
 

4. Resultat

Figur 4.1 Flödesschema över inkluderade systematiska översikter.

4.1 Resultat litteratursökning samt relevans och kvalitetsbedömning

Litteratursökningen resulterade i 19 234 artiklar. I första steget granskades dessa artiklars abstrakt och 2 031 av dem bedömdes som möjligt relevanta. Efter granskning i fulltext bedömdes 1 750 artiklar av 2 031 vara icke-relevanta av någon av följande anledningar (Bilaga 10):

• Identifierad översikt uppfyllde inte kriterierna för en systematisk översikt.
• Språket var annat än engelska, svenska, norska eller danska.
• Ämnesområdet var inte det avsedda – deskriptiv studie, mekanismstudie, området annat än funktionshinder (exempelvis missbruk).
• Kontexten är en annan än avsedd, det vill säga hälso- och sjukvård, habilitering, rehabilitering, utbildning, arbetsliv, kriminalvård.
• Populationen är en annan än avsedd, det vill säga populationerna äldre (65+) med nedsättning av funktionsförmåga som beror enbart av normalt åldrande, populationer som huvudsakligen omfattat personer med diagnoserna Alzheimers sjukdom, åldersrelaterad demens liksom diagnoser som inte samtidigt innebär en funktionsnedsättning.
• Interventionen är en annan än avsedd, det vill säga arbetsmetoder och insatser som skulle kunna tillhandahållas i ett svenskt perspektiv stöds av andra lagstiftningar än de som angivits i Faktaruta 1.2.
• Utfall är annat än avsett, exempelvis utfall kopplade till missbruk.
• Systematisk översikt är publicerad innan år 2000.
• Artikeln är ett duplikat.
• Artikeln är inte möjlig att få tag i.
• Artikeln är inte publicerad i en peer-reviewed tidskrift.
• Identifierad artikel var en bok, avhandling, kommentar från redaktör med mera.

Av de 2 031 artiklar som identifierades som möjligt relevanta bedömdes 281 som relevanta systematiska översikter. Av dessa 281 bedömdes 49 hålla medelhög eller hög metodologisk kvalitet (Bilaga 11). De systematiska översikter som bedömdes ha låg metodologisk kvalitet (232 stycken) brast i en eller flera av följande punkter (Bilaga 12):

• Frågeställningen var inte tydligt definierad i enlighet med PICO/SPICE eller liknande, och/eller inklusions- och exklusionskriterier var inte tydligt angivna.
• Sökningen matchade inte frågeställningen och/eller var inte dokumenterad på ett sådant sätt att den kan återskapas.
• Studiernas relevans hade granskats av färre än två oberoende personer på abstrakt och fulltextnivå och/eller de inkluderade primärstudierna i respektive systematisk översikt fanns inte angivna.
• Inkluderade studier i den systematiska översikten var inte kvalitetsgranskade på ett rimligt sätt. Det var inte transparent hur olika kvalitetsnivåer var satta, det vill säga att kriterier för kvalitetsnivå skulle finnas beskrivna. Kvalitet, karakteristika och resultat på de respektive inkluderade studierna framgick inte tydligt.

4.2 Resultat fördelning av systematiska översikter till livs- och insatsområden

Baserat på sitt innehåll fördelades de systematiska översikter som bedömts vara relevanta (281 systematiska översikter) till de identifierade livs- och insatsområdena (länk till interaktiv karta). Resultatet av fördelningen av relevanta systematiska översikter med medelhög eller hög metodologisk kvalitet (49 systematiska översikter) till livs- och insatsområdena för gruppen personer med funktionsnedsättning finns presenterat i Tabell 4.1. Innehållet i dessa systematiska översikter (49 systematiska översikter) finns sammanfattade i Bilaga 8. För att få en fullständig uppfattning om innehållet behöver varje systematisk översikt läsas i sin helhet.

Tabell 4.1 Personer med funktionsnedsättning. Identifierade relevanta systematiska översikter med medelhög eller hög metodologisk kvalitet fördelade per livs- och insatsområde. 

Det finns systematiska översikter med medelhög eller hög metodologisk kvalitet inom alla tio livsområden. Flest antal systematiska översikter finns inom livsområdena (Tabell 4.1):

• Företa uppgifter samt hantera krav och egen aktivitetsnivå (36 systematiska översikter).
• Personlig vård, hälsa och välmående (29 systematiska översikter).
• Mellanmänskliga interaktioner och relationer (28 systematiska översikter).

Det minsta antalet systematiska översikter med medelhög eller hög metodologisk kvalitet finns inom livsområdena:

• Lärande och att tillämpa kunskap (8 systematiska översikter).
• Rörelse och förflyttning med hjälp av utrustning och transporthjälpmedel (9 systematiska översikter).
• Samhällsgemenskap, socialt samt medborgerligt liv och rättigheter (9 systematiska översikter).

För grupperna anhöriga eller närstående till personer med funktionsnedsättning samt yrkesverksamma finns systematiska översikter med medelhög eller hög metodologisk kvalitet identifierade inom alla tre identifierade livsområden:

• Egen hälsa, välmående och fungerande (14 systematiska översikter) [10,32-37,40,44-49]. Exempel på insatser inom livsområdet är personlig assistans (LSS, SFB), avlösarservice i hemmet (LSS), korttidsvistelse utanför det egna hemmet (LSS), avlösning (SoL), stöd/behandling (SoL) i form av föräldrastöd, föräldrautbildning (exempelvis psykoedukation), kognitiv beteendeterapi (KBT), samt familjeinriktade insatser såsom Stepping Stones Triple P, De otroliga åren, Signpost for Building Better Behaviour Programme, Parent Child Interaction Therapy (PCIT), Parents Plus, Barkley´s Parent Training Programme, Parent Management Training (PMT), familjeterapi, systemisk terapi.
• Föräldraförmåga eller stödjande förmåga (11 systematiska översikter) [8,10-12,15,38,44,45,49-51]. Exempel på insatser inom livsområdet är stöd/behandling (SoL) i form av föräldrastöd, föräldrautbildning (exempelvis psykoedukation), kognitiv beteendeterapi (KBT), samt familjeinriktade insatser såsom Stepping Stones Triple P, De otroliga åren, Signpost for Building Better Behaviour Programme, Parent Child Interaction Therapy (PCIT), Parents Plus, Barkley´s Parent Training Programme, Parent Management Training (PMT), familjeterapi, systemisk terapi, bilstöd för barn (SFB).
• Arbetsmetoder och arbetsverktyg som används för att kartlägga, utreda, bedöma och fastställa tillstånd, fastställa behov av insats, fånga upplevelser erfarenheter eller fatta beslut om insatser för personer med funktionsnedsättning, och deras anhöriga eller andra närstående (1 systematik översikt) [52] (yrkesverksamma).

4.3 Resultat fördelning av systematiska översikter till grupper

Av Figur 4.2 framgår att systematiska översikter som håller medelhög eller hög metodologisk kvalitet saknas helt för grupperna sensorisk funktionsnedsättning; dyslexi, dyskalkyli, språknedsättning samt flerfunktionsnedsättning.

Figur 4.2 Antal identifierade relevanta systematiska översikter medelhög eller hög metodologisk kvalitet.

Samma figur visar att flest av de sammanlagda 49 systematiska översikterna med medelhög eller hög metodologisk kvalitet gäller grupperna ”Neuropsykiatrisk funktionsnedsättning” (24 systematiska översikter) samt ”Anhöriga eller andra närstående till personer med funktionsnedsättning (21 systematiska översikter). Därefter följer grupperna ”Intellektuell funktionsnedsättning” (11 systematiska översikter) samt ”Psykisk funktionsnedsättning” (8 systematiska översikter). För gruppen ”Fysisk funktionsnedsättning” finns det betydligt färre systematiska översikter (5 systematiska översikter) med medelhög eller hög metodologisk kvalitet. Detsamma gäller för ”Yrkesverksamma” (1 systematisk översikt). I en systematisk översikt [37] omfattades gruppen äldre med funktionsnedsättning utan att funktionsnedsättningsgrupp specificerades, den presenteras i figuren under gruppen ”Flera olika funktionsnedsättningsgrupper”. En och samma översikt kan utvärdera flera olika funktionsnedsättningsgrupper och därmed förekomma på flera ställen i figuren.

4.4 Resultat vetenskaplig kunskap och vetenskapliga kunskapsluckor

Vetenskaplig kunskap och vetenskapliga kunskapsluckor för gruppen personer med funktionsnedsättning presenteras i Tabell 4.2 och 4.3. I Tabell 4.2 presenteras de i förhållande till de identifierade systematisk översikterna av medelhög eller hög metodologisk kvalitet som utvärderat insatser riktade till personer med funktionsnedsättning. Tabell 4.3 är en sammanfattande tabell som innehåller den vetenskapliga kunskap och de vetenskapliga kunskapsluckor som identifierats i Tabell 4.2, samt vetenskapliga kunskapsluckor för de insatsområden och funktionsnedsättningsgrupper där inga systematiska översikter av medelhög eller hög metodologisk kvalitet identifierats. I gruppen flera olika funktionsnedsättningar är det en insats som utvärderats, personlig assistans. Personlig assistans har sammanlagt utvärderats i sex systematiska översikter av medelhög eller hög metodologisk kvalitet. Två av dessa utvärderingar avsåg personer med två samtidiga funktionsnedsättningar, som kan men inte behöver vara flerfunktionsnedsättning, medan ytterligare en utvärderade insatsen i förhållande till äldre vuxna utan att funktionsnedsättning var specificerad. För gruppen flera olika funktionsnedsättningar fastställs inte vetenskaplig kunskap eller vetenskapliga kunskapsluckor för några andra insatsområden än personlig assistans. Information om vilken typ av forskning som behövs för att fylla kunskapsluckan finns angiven. Om resultaten i en systematisk översikt baserades på en litteratursökning äldre än år 2014 föreslås en uppdatering av den systematiska översikten oavsett om det var vetenskaplig kunskap eller vetenskaplig kunskapslucka. Ett och samma insatsområde kan innehålla både vetenskaplig kunskap och vetenskapliga kunskapsluckor.

Vetenskaplig kunskap eller vetenskapliga kunskapsluckor fastställdes inte för de systematiska översikter av medelhög eller hög metodologisk kvalitet som handlade om insatser riktade till anhöriga eller andra närstående till personer med funktionsnedsättning [46] [47] [48] [49] [50] [51], samt arbetsmetoder som används av yrkesverksamma inom funktionshinderområdet [52] liksom systematiska översikter vars resultat är baserat på kvalitativa data [8] [17], har ett deskriptivt syfte [42], eller är baserade på primärstudier med en före- och efterdesign med en eller ett fåtal undersökningspersoner [12] [14] [16]. Dessa systematiska översikter presenteras därför inte i Tabell 4.2, men innehållet i dem finns sammanfattat i Bilaga 8. För att få en fullständig bild av innehållet i de systematiska översikterna och vad den fastställda vetenskapliga kunskapen eller vetenskapliga kunskapsluckan i en systematisk översikt består i måste varje systematisk översikt läsas i sin helhet.

Tabell 4.2 Vetenskaplig kunskap och vetenskapliga kunskapsluckor för identifierade relevanta systematiska översikter (SÖ) av medelhög eller hög metodologisk kvalitet för gruppen personer med funktionsnedsättning.

Tabell 4.3 Sammanfattande tabell med vetenskapliga kunskap och de vetenskapliga kunskapsluckor som identifierats i Tabell 4.2, samt vetenskapliga kunskapsluckor för de insatsområden och funktionsnedsättningsgrupper där inga systematiska översikter av medelhög eller hög metodologisk kvalitet identifierats.

4.5 Sammanfattning av resultaten

Syfte med denna kartläggning var att identifiera och kartlägga inom vilka livs- samt insatsområden det finns relevanta systematiska översikter av medelhög eller hög metodologisk kvalitet avseende insatser riktade till personer med funktionsnedsättning, anhöriga eller andra närstående till personer med funktionsnedsättning samt systematiska översikter som utvärderat arbetsmetoder som kan användas av yrkesverksamma inom funktionshinderområdet.

Resultaten visar att det för hela gruppen personer med funktionsnedsättning finns systematiska översikter med medelhög eller hög metodologisk kvalitet inom alla (10 systematiska översikter) för identifierade livsområden. Detsamma gäller för grupperna anhöriga eller närstående till personer med funktionsnedsättning (2 systematiska översikter) samt yrkesverksamma (1 systematisk översikt).

Flest av de sammanlagt 49 systematiska översikterna med medelhög eller hög metodologisk kvalitet gäller grupperna:

• Neuropsykiatrisk funktionsnedsättning (24 systematiska översikter).
• Anhöriga eller andra närstående till personer med funktionsnedsättning (21 systematiska översikter).
• Intellektuell funktionsnedsättning (11 systematiska översikter).
• Psykisk funktionsnedsättning (8 systematiska översikter).
• Fysisk funktionsnedsättning (5 systematiska översikter).

För gruppen yrkesverksamma fanns det en systematisk översikt med medelhög eller hög metodologisk kvalitet.

Systematiska översikter med medelhög eller hög metodologisk kvalitet saknas helt för grupperna:

• Sensorisk funktionsnedsättning.
• Dyslexi, dyskalkyli, språknedsättning.
• Flerfunktionsnedsättning.

Syftet var vidare att utifrån relevanta systematiska översikter med medelhög eller hög metodologisk kvalitet samt identifierade insatsområden beskriva var det finns vetenskaplig kunskap eller vetenskapliga kunskapsluckor för insatser till personer med funktionsnedsättning.

Vetenskaplig kunskap identifierades för gruppen:

• Neuropsykiatrisk funktionsnedsättning inom 8 av 17 insatsområden.
• Psykisk funktionsnedsättning inom 4 av 17 insatsområden.
• Intellektuell funktionsnedsättning inom 4 av 17insatsområden.
• Fysisk funktionsnedsättning inom 2 av 17 insatsområden.

Vetenskapliga kunskapsluckor fastställdes enligt nedan:

• Psykisk funktionsnedsättning inom 13 av 17 insatsområden.
• Neuropsykiatrisk funktionsnedsättning inom 9 av 17 insatsområden.
• Intellektuell funktionsnedsättning inom 13 av 17 insatsområden.
• Fysisk funktionsnedsättning inom 15 av 17 insatsområden.

Då det helt saknades systematiska översikter av medelhög eller hög kvalitet inom alla insatsområden för grupperna sensorisk funktionsnedsättning, dyslexi, dyskalkyli, språknedsättning, samt flerfunktionsnedsättning föreligger det enligt SBU:s definition vetenskapliga kunskapsluckor inom alla (17) insatsområden.

Personlig assistans har sammanlagt utvärderats i sex systematiska översikter av medelhög eller hög metodologisk kvalitet. Två av dessa översikter avsåg personer med flera olika funktionsnedsättningar, som kan men inte behöver vara flerfunktionsnedsättning, medan ytterligare en utvärderade insatsen i förhållande till äldre vuxna utan att funktionsnedsättning var specificerad. För denna grupp (personer med flera olika funktionsnedsättningar) fastställs inte vetenskaplig kunskap eller vetenskapliga kunskapsluckor för några andra insatsområden än personlig assistans. För grupperna vuxna med både fysisk och intellektuell funktionsnedsättning, liksom äldre med flera olika funktionsnedsättningar finns viss vetenskaplig kunskap. När det gäller barn och ungdom med både fysisk och intellektuell funktionsnedsättning) bedömdes det vara en vetenskaplig kunskapslucka.

De insatsområden där flest vetenskapliga kunskapsluckor finns är:

• Autonomirelaterade insatser
• Boenderelaterade insatser
• Föräldraförmågafrämjande insatser
• Motivationsinriktade insatser
• Transportrelaterade insatser.

Kartläggningen gäller systematiska översikter som utvärderat insatser och arbetsmetoder inom socialtjänst, samt insatser som ligger utanför socialtjänst, såsom exempelvis färdtjänst och bostadsanpassning, samt statliga insatser som assistansersättning och bilstöd liksom en arbetsmarknadspolitisk insats (SIUS). Arbetsmetoder och insatser inom hälso- och sjukvård (inklusive habilitering, rehabilitering, vardagstolkning och hjälpmedel), utbildning, arbetsliv eller kriminalvård ingår därmed inte i kartläggningen vilket innebär att kunskapsläget kan se annorlunda ut inom dessa områden för flera av funktionsnedsättningsgrupperna.

Resultaten som presenteras baseras på litteratursökning som omfattar åren 2000–2017. Det kan ha publicerats nya systematiska översikter av medelhög eller hög metodologisk kvalitet efter år 2017 vilket kan förändra kunskapsläget och därmed resultaten i denna kartläggning. Det kan ha tillkommit ytterligare primärstudier efter att en översikt publicerats vilket också kan förändra kunskapsläget.

5. Projektgrupp, externa granskare, bindningar och jäv

5.1 Externa sakkunniga

• Mikaela Starke, professor vid institutionen för socialt arbete, Göteborgs universitet
• Ann-Marie Öhrvall, medicine doktor och leg. arbetsterapeut, Karolinska institutet

5.2 SBU

• Susanna Larsson Tholén, projektledare, SBU, sakkunnig på SBU, sakkunnig för rapporten sedan maj 2017, projektledare för rapporten sedan september 2017
• Helena Domeij, projektledare, SBU, genomfört abstraktgranskning, kvalitetsgranskning samt fastställt kunskap och kunskapsluckor
• Christel Hellberg, projektledare, SBU samt samordnare för publikationstypen SBU Kartlägger, projektledare för rapporten under uppstartsfas, genomfört abstraktgranskning samt fastställt kunskap och kunskapsluckor
• Maria Ahlberg, projektadministratör
• Maja Kärrman Fredriksson, informationsspecialist
• Jenny Stenman, projektadministratör

5.3 Externa granskare

Jens Ineland, universitetslektor vid Institutionen för socialt arbete, Umeå universitet
Thomas Strandberg, universitetslektor vid Institutionen för juridik, psykologi och socialt arbete, Örebro universitet

5.4 Bindningar och jäv

Sakkunniga och granskare har i enlighet med SBU:s krav inlämnat deklaration rörande bindningar och jäv. Dessa dokument finns tillgängliga på SBU:s kansli. SBU har bedömt att de förhållanden som redovisas där är förenliga med kraven på saklighet och opartiskhet. 

5.5 SBU:s vetenskapliga råd

SBU:s vetenskapliga råd har granskat det vetenskapliga underlaget i rapporten.

• Svante Twetman, Köpenhamns universitet, ordförande (tandvård)
• Christel Bahtsevani, Malmö universitet, vice ordförande (omvårdnad)
• Magnus Svartengren, Uppsala universitet (arbetsmiljö)
• Ulrik Kihlbom, Uppsala universitet (etik)
• Lars Sandman, Linköpings universitet (etik)
• Magnus Tideman, Högskolan Halmstad (funktionshinderområdet)
• Pernilla Åsenlöf, Uppsala universitet (fysioterapi)
• Martin Henriksson, Linköpings universitet (hälsoekonomi)
• Katarina Steen Carlsson, Lunds universitet (hälsoekonomi)
• Jan Holst, Malmö och Lunds universitet (medicin)
• Mussie Msghina, Örebro universitet (medicin)
• Britt-Marie Stålnacke, Umeå universitet (medicin)
• Sverker Svensjö, Falun och Uppsala universitet (medicin)
• Anna Ehrenberg, Falun, Högskolan Dalarna (omvårdnad)
• Ata Ghaderi, Uppsala, Karolinska institutet (psykologi)
• Martin Bergström, Lunds universitet (socialt arbete)
• Lena Dahlberg, Falun, Högskolan Dalarna (socialt arbete)
• Christina Nehlin-Gordh, Uppsala universitet (socialt arbete)
• Anna Sarkadi, Uppsala universitet (socialmedicin)
• Sten-Åke Stenberg, Stockholms universitet (socialt arbete)

6. Ordförklaringar och förkortningar

ABI

Acquired Brain Injury

ADD

Attention Deficit Disorder

ADHD

Attention Deficit Hyperactivity Disorder

AMSTAR

AMSTAR är en gransk­nings­mall för att utvärdera kvali­teten på en syste­matisk över­sikt bestå­ende av elva olika frågor

ASD

Aspergers syndrom

CBT

Cognitive Behavioral Therapy

Dyskalkyli

Specifika matematik­svårigheter.

Dyslexi

Specifika läs- och skriv­svårigheter

FB

Föräldrabalk (1949:381).

FIAP

Fostering Individualized Assistance Program

ICF

International Classification of Functioning, Disability and Health.

Internationell klassi­fikation av funktions­tillstånd, funktions­hinder och hälsa är en medicinsk klassi­fikation, som antogs av Världs­hälso­organi­sationen den 22 maj 2001. ICF ersatte den tidigare Interna­tionella klassi­fika­tionen av funktions­nedsättning, funktions­hinder och handikapp.

IFN

Intellektuell funktions­nedsättning

Kartläggning av syste­matiska översikter

En systematisk kart­läggning utgår från en bred litteratur­sökning efter befintliga syste­matiska översikter. De översikter som upp­fyller urvals­kriterierna kvalitets­granskas med hjälp av AMSTAR gransknings­mall. De översikter som bedöms ha hög och medel­hög kvalitet sorteras sedan in i på för­hand utvalda domäner för att bedöma var det finns veten­skaplig kunskap och var det finns veten­skapliga kunskaps­luckor. I projektet kvalitets­granskas endast de syste­matiska över­sikterna. De primär­studier som ingår i de syste­matiska över­sikterna granskas inte.

LBB

Lag (2018:222) om bostads­anpassnings­bidrag.

LFF

Lag (2017:310) om framtids­fullmakter.

LFT/LRFT

Lagarna om färdt­jänst (1997:736) och riksfärd­tjänst (1997:735)

LSS

Lag (1993:387) om stöd och service till vissa funktions­hindrade.

PCIT

Parent–Child Interaction Therapy

PICO

Population, Intervention, Comparison, Outcome

Primärstudie

En studie som innehåller nya resultat, och inte enbart bygger på redan publi­cerad forskning benämns primär­studie. Termen används för att särskilja mot sekundär­studier som innebär analyser av tidigare studier, som till exempel en syste­matisk översikt eller en översikts­artikel.

RCT

Randomiserad kontrol­lerad studie (Randomised Controlled Trial)

SFB

Socialförsäkringsbalk (2010:110).

SoL

Socialtjänstlag (2001:453).

SPICE

(Setting, Perspective, Intervention, Comparison, Evaluation).

SVU

Lag (2017:612) om samverkan vid utskriv­ning från sluten hälso- och sjukvård

Systematisk översikt (SÖ)

En systematisk översikt är en kunskaps­samman­ställning av primär­studier avseende en tydlig och avgränsad fråga. För att göra en syste­matisk översikt används en struktu­rerad och transparent metod för att finna, välja ut, kritiskt bedöma samt samman­fatta studier relevanta för fråge­ställningen. En bra syste­matisk översikt följer vissa principer som ska minimera riskerna för att slump eller godtyck­lighet påverkar slutsatserna.

TEACCH

Treatment and Education of Autistic and Related Communication Handicapped Children

ToM

Theory of Mind. Betyder att man har för­mågan att förstå skillnaden mellan sitt eget och andra människors sätt att tänka, känna och handla.

Vetenskaplig kunskapslucka (VKL)

Enligt SBU föreligger en veten­skaplig kunskaps­lucka om en eller flera syste­matiska översikter av medel­hög eller hög kvalitet visar på en osäker effekt av en metod, insats eller åtgärd eller syste­matiska över­sikter av hög eller medelhög kvalitet saknas.

VVK

Viss vetenskaplig kunskap finns

7. Referenser

1. SBU. Missbruk och beroende av alkohol och narkotika – Kunskapsläget för utredningar och insatser inom socialtjänsten. En kartläggning av systematiska översikter. Stockholm: Statens beredning för medicinsk och social utvärdering (SBU); 2019. SBU-rapport nr 296. ISBN 978-91-88437-38-9. 296/2019.
2. SBU. Ekonomiskt bistånd – kunskapsläget för utredning och insatser. Vetenskaplig kunskap och kunskapsluckor utifrån systematiska översikter. Stockholm: Statens beredning för medicinsk och social utvärdering (SBU); 2018. SBU-rapport nr 274. ISBN 978-91-88437-16-7.: SBU. 274/2018.
3. SBU. Kunskapsläget för bedömning och insatser inom äldreomsorgen. Identifiering av vetenskaplig kunskap och kunskapsluckor utifrån systematiska översikter. Stockholm: Statens beredning för medicinsk och social utvärdering (SBU); 2019. SBU-rapport nr 306.
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9. Ali A, Hall I, Blickwedel J, Hassiotis A. Behavioural and cognitive-behavioural interventions for outwardly-directed aggressive behaviour in people with intellectual disabilities. Cochrane Database Syst Rev. 2015;CD003406.
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Tabeller Kapitel 4 och Bilaga 8

Tabeller Kapitel 4 och Bilaga 8 (pdf)

Bilaga 1 Lagstiftning och andra rättsdokument.

Sverige har ratificerat flera internationella konventioner, där FN:s konvention om rättigheter för personer med funktions­nedsättning och FN:s konvention om barnets rättigheter (Barnkonventionen) är särskilt viktiga för området. Dessa konventioner har inte status av lag i rättslig mening men har ett betydande värde för svensk rätt på andra sätt. Dels inverkar konventionerna indirekt genom att det statliga styr- och kontrollsystemen har som mål att säkra konventionskraven genom nationella lagstiftningsåtgärder och genom politisk uppmärksamhet och prioritering, dels ska svensk rätt tolkas utifrån vad konventionerna uttalar. Med andra ord fyller dessa två ratificerade konventioner en viktig funktion i många lagstiftnings- som beslutssammanhang.

Det finns ett antal nationella lagstiftningar som, i sin helhet eller delar av, är specifikt riktade till personer med funktionsnedsättning. Nedan finns lagstiftningar beskrivna som är identifierade som utgångspunkter för utvärdering av insatser inom det sociala området.

Lag (1993:387) om stöd och service till vissa funktionshindrade (LSS)

LSS ska garantera personer med omfattande och varaktiga funktionsnedsättningar goda levnadsvillkor, att personer inom denna grupp får det stöd de behöver i det dagliga livet samt att de kan påverka vilket stöd och vilken service de får. Målet är att varje enskild person får möjlighet att leva som andra.

De tre personkretsarna i LSS avgör vilka målgrupper som omfattas av LSS (och Socialförsäkringsbalkens 51 kap. Assistansersättning).

• Personkrets 1: Personer med utvecklingsstörning, autism eller autismliknande tillstånd.
• Personkrets 2: Personer med betydande och bestående begåvningsmässig funktionsnedsättning efter hjärnskada i vuxen ålder föranledd av yttre våld eller kroppslig sjukdom.
• Personkrets 3: Personer med andra varaktiga fysiska eller psykiska funktionsnedsättningar som uppenbart inte beror på normalt åldrande, om de är stora och förorsakar betydande svårigheter i den dagliga livsföringen och därmed ett omfattande behov av stöd eller service.

Inom ramen för LSS ryms tio insatser:

• Rådgivning och annat personligt stöd som ställer krav på särskild kunskap om problem och livsbetingelser för människor med stora och varaktiga funktions­hinder/funk­tions­nedsätt­ningar, enligt 9 § 1 i LSS: En rätt till kvalificerat expertstöd av personal som förutom sin yrkeskunskap har särskild kunskap om hur det är att leva med stora funktions­hinder/funktions­nedsätt­ningar. Stödet kan till exempel ges av kurator, psykolog, sjukgymnast, förskole­konsulent, logoped, arbetsterapeut eller dietist. Råd och stöd ska vara ett komplement till och inte en ersättning för till exempel habilitering, rehabilitering och socialtjänst. Habilitering är utförare.
• Biträde av personlig assistent eller ekonomiskt stöd till skäliga kostnader för sådan assistans, till den del behovet av stöd inte täcks av beviljade assistanstimmar enligt 51 kap. Socialförsäkringsbalken (SFB), enligt 9 § 2 i LSS: Personlig assistans skall vara ett personligt utformat stöd som ges av ett begränsat antal personer åt den som på grund av stora och varaktiga funktions­nedsättningar behöver hjälp med sin personliga hygien, måltider, att klä sig, att kommunicera med andra eller annan hjälp som förutsätter ingående kunskap om den funktionshindrade (grund­läggande behov) (9 a § i LSS). Om personen behöver personlig assistans som i genomsnitt omfattar mer än 20 timmar i veckan för grundläggande behov kan han eller hon ha rätt till assistansersättning enligt 51 kap. Social­försäkrings­balken. Personlig assistans regleras både i LSS och Social­försäkrings­balken (2010:110) 51 kap. då assistansreformen är ett delat ansvar mellan kommuner och stat. Den statliga assistansersättningen beviljas personer som tillhör någon av de tre personkretsarna i LSS och som har ett behov av assistans som överstiger 20 timmar per vecka. I de fall personen ansöker om assistansersättning är det Försäkringskassan som utreder, beslutar och betalar ut ersättningen. Det stöd som tillhandahålls genom assistansersättning motsvarar det stöd som tillhandahålls genom personlig assistans enligt LSS.
• Ledsagarservice, enligt 9 § 3 i LSS: Ledsagarservice ska vara en personlig service, anpassad efter individuella behov som ska kunna underlätta för den enskilde att delta i samhällslivet. Denna stödform ska underlätta för personer med omfattande funktionsnedsättningar att med stöd av en följeslagare komma ut och delta i samhällslivet, till exempel att besöka vänner, delta i fritidsaktiviteter eller kulturlivet.
• Biträde av kontaktperson, enligt 9 § 4 i LSS: Personligt stöd för att bryta isolering och för att underlätta ett självständigt liv.
• Avlösarservice i hemmet, enligt 9 § 5 i LSS: Avlösarservice ska kunna fås både som en regelbunden insats och för situationer som inte kan förutses. Den ska vara tillgänglig alla tider på dygnet. möjliggöra att anhöriga får avkoppling eller uträtta sysslor utanför hemmet.
• Korttidsvistelse utanför det egna hemmet, enligt 9 § 6 i LSS: Vistelse i korttidshem, hos stödfamilj eller som lägervistelse utanför det egna hemmet för att en person med funktionsnedsättning ska få miljöombyte och rekreation eller för att ge anhörig avlastning.
• Korttidstillsyn för skolungdom över 12 år utanför det egna hemmet i anslutning till skoldagen samt under lov, enligt 9 § 7 i LSS: Tillsyn före och efter skoldagens slut, under lovdagar, studiedagar och längre lov utanför det egna hemmet för skolbarn över 12 år med funktionsnedsättning.
• Boende i familjehem eller bostad med särskild service för barn eller ungdomar som behöver bo utanför föräldrahemmet, enligt 9 § 8 i LSS: Insats som ges till barn eller ungdomar som av skilda skäl inte kan bo hos sina föräldrar och istället kan erbjudas boende i familjehem eller i bostad med särskild service för barn eller ungdomar.
• Bostad med särskild service för vuxna eller annan särskilt anpassad bostad för vuxna, enligt 9 § 9 i LSS: Bostäder till personer i vuxen ålder som har behov av stöd, service och omvårdnad. Gruppbostad och servicebostad är de vanligaste formerna. Den enskilde kan också ha rätt att få en särskild anpassad bostad anvisad av kommunen.
• Daglig verksamhet enligt 9 § 10 i LSS: Personer i yrkesverksam ålder, som saknar förvärvsarbete och inte utbildar sig, har rätt till daglig verksamhet om de ingår i personkrets 1 och 2 enligt LSS. Den dagliga verksamheten bör kunna innehålla såväl aktiviteter med habiliterande inriktning som mer produktionsinriktade uppgifter. Insatsen ska anpassas efter individuella behov, förutsättningar och intressen

Socialförsäkringsbalk (2010:110) (SFB)

Särskilda insatser till personer med funktionsnedsättning regleras i Socialförsäkringsbalkens:

• 22 kap. Omvårdnadsbidrag
• 30–31 kap. Rehabilitering
• 33–36 kap. Allmänna bestämmelser om sjukersättning och aktivitetsersättning
• 49 kap. Särskilda förmåner vid funktionsnedsättning
• 50 kap. Merkostnadsersättning
• 51 kap. Assistansersättning
• 52 kap. Bilstöd
• 101 kap. Rätten till bostadstillägg

Socialtjänstlag (2001:453) (SoL)

Personer med funktionsnedsättning kan förutom insatser enligt LSS ha rätt till insatser i enlighet med SoL. Detta exempelvis i fall där personen inte bedöms tillhöra någon av LSS personkretsar. Insatser i enlighet med både LSS och SoL kan ges samtidigt. I SoL regleras att kommunerna har ett särskilt ansvar för vissa grupper i samhället, däribland personer med funktionsnedsättning. Enligt 5 kap. 7 § i SoL ska kommunerna verka för att människor som av fysiska, psykiska eller andra skäl möter betydande svårigheter i sin livsföring får möjlighet att delta i samhällets gemenskap och att leva som andra. Enligt samma paragraf skall Socialnämnden medverka till att den enskilde får en meningsfull sysselsättning och får bo på ett sätt som är anpassat efter hans eller hennes behov av särskilt stöd. Vidare bör nämnden genom hemtjänst, dagverksamheter eller annan liknande social tjänst underlätta för den enskilde att bo hemma och att ha kontakt med andra. Kommunen ska också inrätta bostäder med särskild service för de som behöver sådan bostad (5 kap. 7 § tredje stycket i SoL). SoL reglerar insatser i form av:

• Annat bistånd
• Avlösning
• Behandling
• Boendestöd
• Dagverksamhet
• Ekonomiskt bistånd
• Hemtjänst
• Kontaktperson/familj
• Korttidsplats
• Ledsagning/Ledsagare
• Matdistribution
• Särskilt boende
• Trygghetslarm
• Uppsökande verksamhet

Hälso- och sjukvårdslag (2017:30) (HSL)

Särskilda insatser till personer med funktionsnedsättning regleras i HSL:s 8 kap. 7 §, 10 kap. 2 § och 12 kap. 5 § 0m habilitering, rehabilitering, hjälpmedel och tolktjänst samt 18 kap. 3 § som reglerar samarbete i fråga om personer med psykisk funktionsnedsättning. Med habilitering avses insatser som ska bidra till att en person med medfödd eller tidigt förvärvad funktionsnedsättning utvecklar och bibehåller bästa möjliga funktionsförmåga samt skapar goda villkor för ett självständigt liv och ett aktivt deltagande i samhällslivet [303]. Stödet anpassas medicinskt, psykologiskt, socialt och pedagogiskt utifrån personens behov och följande kan ingå:

• Information om personens funktionsnedsättning.
• Behandling för motorisk och språklig utveckling.
• Behandling, stöd och insatser för psykisk och social utveckling.
• Behandling, stöd och insatser för att utveckla socialt samspel.
• Stöd och utprovning av hjälpmedel för att kunna göra vardagsaktiviteter.
• Råd inför bostadsanpassning och annan anpassning av miljön.
• Samtalsstöd.

Rehabilitering avses liknande insatser till målgruppen personer med förvärvad funktionsnedsättning. Den för tolktjänst mest centrala bestämmelsen finns i HSL enligt vilken landstingen är skyldiga att erbjuda tolktjänst för vardagstolkning för barndomsdöva, dövblinda, vuxendöva och hörselskadade.

Patientlag (2014:821) (PL)

I kap 7 § 2 finns en specialbestämmelse som avser rätten att välja hjälpmedel.

Lag (1993:584) om medicintekniska produkter (LMP)

Hjälpmedel som förskrivs är oftast medicintekniska produkter.

Lag (2008:145) om statligt tandvårdsstöd (STF)

STF 4a § reglerar vid vilka sjukdomar/funktionsnedsättningar som man kan rätt till särskilt tandvårdsbidrag.

Lag (2017:612) om samverkan vid utskrivning från sluten hälso- och sjukvård (SVU)

I lagstiftningen regleras bestämmelser om samverkan vid planering av insatser för enskilda som efter att de skrivits ut från sluten vård kan komma att behöva insatser från socialtjänsten, den kommunalt finansierade hälso- och sjukvården eller den regionfinansierade öppna vården. Detta kan vara aktuellt för personer med funktionsnedsättning som har insatser enligt LSS och SoL.

Lag (1991:1128) om psykiatrisk tvångsvård (LPT)

LPT är ett komplement till HSL och PL i fråga om psykiatrisk vård där vården är förknippad med ett frihetsberövande eller annat tvång (LPT 1 §). Syftet med lagstiftningen är för att skydda den enskilde och vården ska syfta till att sätta patienten i stånd att frivilligt medverka till nödvändig vård och ta emot det stöd som han eller hon behöver (2 §). Enligt LPT 3 § Tvångsvård får ges endast om patienten lider av en allvarlig psykisk störning och på grund av sitt psykiska tillstånd och sina personliga förhållanden i övrigt har ett oundgängligt behov av psykiatrisk vård, som inte kan tillgodoses på annat sätt än genom att patienten är intagen på en sjukvårdsinrättning för kvalificerad psykiatrisk dygnetruntvård (sluten psykiatrisk tvångsvård), eller behöver iaktta särskilda villkor för att kunna ges nödvändig psykiatrisk vård (öppen psykiatrisk tvångsvård). Tvångsvård får inte ges om patientens psykiska störning enligt första stycket utgör enbart en utvecklingsstörning.

Lag (1991:1129) om rättspsykiatrisk vård (LRV)

Ytterligare en lagstiftning som hanterar vård inom det psykiatriska området är Lag (1991:1129) om rättspsykiatrisk vård (LRV). Lagstiftningen gäller den som efter beslut av domstol skall erhålla psykiatrisk vård. LRV är kopplad till HSL eftersom den ger regioner/landsting en skyldighet att tillhandahålla psykiatrisk vård.

Lagarna om färdtjänst (1997:736) och riksfärdtjänst (1997:735) (LFT/LRFT)

Kommunerna ansvarar för att tillhandahålla färdtjänst, det vill säga särskilt anordnade transporter, av god kvalitet till kommuninvånare med funktionsnedsättning. Färdtjänst anordnas inom kommunen och kan också anordnas till andra kommuner. Lag om riksfärdtjänst reglerar att kommuner ska lämna ersättning för reskostnader för personer som till följd av en stor och varaktig funktionsnedsättning måste resa på ett särskilt kostsamt sätt. Detta gäller resor mellan kommuner och där resor inte kan göras med allmänna kommunikationer eller kräver ledsagare.

Lag (2018:222) om bostadsanpassningsbidrag (LBB)

Lag om bostadsanpassningsbidrag har till ändamål att genom bidrag till anpassning av bostäder ge personer med funktionsnedsättning möjlighet till ett självständigt liv i eget boende. Kommunerna svarar för att bidrag lämnas till anpassning och återställning av bostäder och Boverket har tillsyn över kommunernas bidragsverksamhet.

Lag (2017:310) om framtidsfullmakter (LFF)

Lag om framtidsfullmakt reglerar fullmaktsförhållanden som avser hjälp med att fatta beslut om ekonomiska och personliga frågor på grund av sjukdom, psykisk störning, försvagat hälsotillstånd eller något liknande förhållande. Det är en form av ställföreträdarskap som den enskilde utformar inför en framtida oförmåga att fatta beslut och som kompletterar systemen med god man och förvaltare.

Föräldrabalk (1949:381) (FB)

I kapitel 11 och 12 regleras det om god man samt förvaltare. Kommunerna ansvarar för att det finns överförmyndare eller överförmyndarnämnd och Länsstyrelserna har tillsyn över överförmyndarna. I kapitel 6 regleras det så kallade föräldraansvaret.

Förordning (2017:462) om särskilda insatser för personer med funktionsnedsättning som medför nedsatt arbetsförmåga

De särskilda insatserna är:

• Bidrag till hjälpmedel på arbetsplatsen, litteratur och tolk för personer med syn- eller hörselnedsättning liksom för personligt biträde och uppstartskostnader vid start av näringsverksamhet
• Särskild stödperson för introduktion och uppföljning (SIUS).
• Lönebidrag
• Skyddat arbete

Plan- och bygglag (2010:900) (PBL)

Reglerar krav på fysisk tillgänglighet i byggnader och på allmän mark.

Lag (1979:558) om handikappanpassad kollektivtrafik (LHK)

Lagen gäller anpassning av kollektivtrafik så att den är funktionell oavsett funktionstillstånd.

Diskrimineringslag (2008:567) (DL)

Diskrimineringslagen ska motverka diskriminering på grund av kön, etnisk tillhörighet, religion eller annan trosuppfattning, funktionsnedsättning, sexuell läggning, könsöverskridande identitet eller uttryck och ålder. Diskrimineringsskyddet gäller i arbetsliv, utbildning, hälso- och sjukvård, socialtjänst, socialförsäkringssystemet, arbetslöshetsförsäkringen, studiestöd, värnplikt, offentlig anställning med mera.

Arbetsmiljölag (1977:1160) (AML)

Lagen betonar att arbetsförhållandena ska anpassas till och tillgängliggöras i förhållande till människors olika fysiska och psykiska förutsättningar. Arbetsmiljön skall enligt lagstiftningen möjliggöra delaktighet och jämlikhet för personer med funktionsnedsättning och karaktäriseras av tillgänglighet och användbarhet för personer med olika typer av funktionsnedsättningar när det gäller information, produkter, tjänster och miljöer.

Skollag (2010:800) (SL)

Skollagen reglerar vilka rättigheter och skyldigheter barn, elever och vårdnadshavare har och i lagen står vilka krav som ställs på huvudmannen för verksamheten. I 3 kap, 2 § anges att elever som till följd av en funktionsnedsättning har svårt att uppfylla de olika kunskapskrav eller kravnivåer som finns ska ges stöd som syftar till att så långt som möjligt motverka funktionsnedsättningens konsekvenser. Detta kan ske genom stöd i form av extra anpassningar (5 §) och utredning av elevens behov av särskilt stöd (7 §). I 11, 12 och 19 kapitlet finns bestämmelser om grundsärskolan, specialskolan och utbildning på program i gymnasiesärskolan.

Språklag (2009:600)

I språklagen finns bestämmelser om språkliga rättigheter och det svenska teckenspråket (teckenspråk är dövas förstaspråk sedan år 1981), liksom om det allmännas ansvar för att den enskilde ges tillgång till språk samt om språkanvändning i offentlig verksamhet och i internationella sammanhang. Enligt 9 § har det allmänna har ett särskilt ansvar för att skydda och främja det svenska teckenspråket och den som är döv eller hörselskadad och den som av andra skäl har behov av teckenspråk skall enligt 14 § ges möjlighet att lära sig, utveckla och använda det svenska teckenspråket. Institutet för språk och folkminnen och deras språkvårdsenhet, Språkrådet, arbetar med det svenska teckenspråket och följer hur språklagen tillämpas liksom stödjer klarspråksarbetet inom myndigheter. Specialpedagogiska skolmyndigheten är en annan myndighet som aktivt arbetar för att synliggöra teckenspråket.

Lag om offentlig upphandling (2016:1145) (LOU) samt Lag (2016:1146) om upphandling inom försörjningssektorerna (LUF)

LOU gäller vid offentlig upphandling av byggentreprenader, varor och tjänster samt av byggkoncessioner och LUF gäller för upphandling som genomförs för verksamhet inom områdena vatten, energi, transporter eller posttjänster. Upphandlingsreglerna innehåller en skyldighet för upphandlande myndigheter och enheter att bestämma de tekniska specifikationerna med beaktande av samtliga användares behov, däribland tillgänglighet för personer med funktionsnedsättning (LOU respektive LUF 9 kap, 2 §). 

Lag (2008:962) om valfrihetssystem (LOV)

Lagstiftningen reglerar hur kontrakt upprättas vid beslut om valfrihet avseende tjänster inom hälsovård och socialtjänst. Med valfrihetssystem avses ett förfarande där den enskilde har rätt att välja den leverantör som ska utföra tjänsten och som en upphandlande myndighet godkänt och tecknat kontrakt med. Tjänster som kan utföras med stöd av LOV är insatser enligt LSS och SoL såsom daglig verksamhet och hemtjänst.

Förvaltningslag (2017:900) (FL)

Förvaltningslagen anger allmänna regler för kontakten mellan myndigheter och enskilda. I 6 § stadgas serviceskyldigheten, det vill säga att myndighet ska se till att kontakterna med enskilda blir smidiga och enkla, samt lämna den enskilde sådan hjälp att han eller hon kan ta till vara sina intressen. Hjälpen ska ges i den utsträckning som är lämplig med hänsyn till frågans art, den enskildes behov av hjälp och myndighetens verksamhet. För att den enskilde ska kunna ta till vara sin rätt har person med funktionsnedsättning som allvarligt begränsar förmågan att se, höra eller tala skall myndighet använda tolk och göra innehåll i handlingar tillgängliga.

Kommunallag (2017:25) (KL)

Kommunallagen slår fast att kommuner och landsting ska behandla sina medlemmar lika, om det inte finns sakliga skäl för något annat (2 kap, 2 §). Lagen ställer även krav på att förtroendevalda med funktionsnedsättning ska kunna delta i handläggningen av ärenden på samma villkor som andra förtroendevalda (4 kap, 33 §).

Vallag (2005:837) (VL)

En kommun måste använda en vallokal som är tillgänglig för väljare med funktionsnedsättning. Undantag får endast ske om kommunen inte kan använda en lokal som är tillgänglig. Om kommunen planerar att använda en otillgänglig lokal måste det ske i samråd med Länsstyrelsen innan beslut tas.

Regeringsformen (1974:152) (RF)

I grundlagen, regeringsformen, står att det ”allmänna ska verka för att alla människor ska kunna uppnå delaktighet och jämlikhet i samhället och för att barns rätt tas till vara. Det allmänna ska motverka diskriminering av människor på grund av kön, hudfärg, nationellt eller etniskt ursprung, språklig eller religiös tillhörighet, funktionsnedsättning, sexuell läggning, ålder eller andra omständigheter som gäller den enskilde som person.” (1 kap, § 2). 

Förordning (2001:526) om de statliga myndigheternas ansvar för genomförande av funktionshinderpolitiken

Förordningen anger att alla statliga myndigheter ska verka för att deras lokaler, verksamhet och information är tillgängliga för personer med funktionsnedsättning. 

Bilaga 2 Exempel på insatser och arbetsmetoder inom funktionshinderområdet.

Personer med funktionsnedsättning

Insatser – exempel

Allmänna och universella insatser

• Allmänna delaktighetsfrämjande insatser
• Tillgång till språk (Språklag (2009:600))
• Tillgängliga medier, allmänna krav:
  Lättläst material, punktskrift, taltidningar 
• Talböcker
• Samhällsintegrering
• Allmänna insatser för att motverka diskriminering och stigma (Diskrimineringslag (2008:567) (DL))
• Allmänna krav och insatser i bostäder och byggd miljö (Plan- och bygglag (2010:900) (PBL))
• Allmänna krav på tillgängliga transporter (Lag (1979:558) om handikappanpassad kollektivtrafik (LHK))
• Attityd – och beteende påverkande insatser
• Universell utformning.

Individuella insatser

• Utbildning, arbete-, sysselsättnings- och fritidsinriktade insatser
• Insatser inom skola och utbildning (Skollag (2010:800) (SL))
• Arbetsmiljöinsatser (Arbetsmiljölag (1977:1160) (AML))
• Arbetsmarknadspolitiska insatser (Förordning (2017:462) om särskilda insatser för personer med funktionsnedsättning som medför nedsatt arbetsförmåga (API))
• Personligt biträde. För person med funktionsnedsättning som behöver hjälp med vissa arbetsuppgifter kan personligt biträde beviljas. Arbetsgivaren kompenseras ekonomiskt
• SIUS
• Pedagogiskt stöd vid deltagande i utbildning via Arbetsförmedlingen
• Arbete på Samhall
• Individuellt anpassat stöd när man söker jobb
• Vägledning för att övergång från skolan till arbetslivet ska bli så smidig som möjlig
• Psykosocialt anpassningsstöd
• Arbetslivsinriktad rehabilitering
• Bidrag till person med funktionsnedsättning för hjälpmedel som underlättar på arbetsplatsen.
• Skyddat arbete hos offentlig arbetsgivare.
• Insatser för att underlätta övergång till arbetsliv/transitionsinsatser
• Anställning och stöd/Supported Employment
• Individuell placering och stöd (Individual Placement and Support)
• Sensoriska insatser såsom upplevelserum
• Daglig verksamhet (Lag (1993:387) om stöd och service till vissa funktionshindrade (LSS))
• Dagverksamhet (Socialtjänstlag (2001:453) (SoL))
• Involvering i fritidsaktiviteter.

Autonomirelaterade insatser

• Rådgivning och annat personligt stöd (LSS)
• Rådgivning och stöd (SoL, Hälso- och sjukvårdslag (2017:30) (HSL))
• Personliga budgetar för att kunna köpa sociala välfärdstjänster (SoL, LSS, m.fl.)
• God man, förvaltare (Föräldrabalk (1949:381) (FB))
• Framtidsfullmakter (Lag (2017:310) om framtidsfullmakter (LFF)).

Beteendeinriktade insatser

• Tillämpad beteendeintervention (TBI)
• Metoder/strategier som bygger på TBI såsom funktionell analys, pivotal responsträning, positivt beteendestöd (PBS) med flera.
• Funktionell kommunikationsträning
• Miljöträning.

Boenderelaterade insatser

• Bostadsanpassning, Lag (2018:222) om bostadsanpassningsbidrag (LBB)
• Bostad med särskild service för vuxna eller annan särskilt anpassad bostad enligt LSS)
• Särskilt boende för personer med funktionsnedsättning (SoL)
• Boendestöd (SoL)
• Hemtjänst (SoL)
• Trygghetslarm (SoL)
• Matdistribution (SoL)
• Korttidsboende (SoL).

Delaktighets- och socialt främjande insatser

• Ledsagarservice (LSS, SoL)
• Kontaktperson (LSS) (SoL). Kontaktperson enligt socialtjänstlagen kan beviljas om den enskilde har ett begränsat socialt nätverk, riskerar isolering eller har behov av att bryta isolering.
• Korttidsvistelse utanför det egna hemmet (LSS). Korttidshem, korttidsfamilj, läger
• Korttidstillsyn för skolungdom över 12 år (LSS)
• Social färdighetsträning (Social skills interventions). Insatser som avser att påverka förmågan att kommunicera med andra och utveckla samt bibehålla sociala relationer.

Ekonomiska ersättningar, Socialförsäkringsbalk (2010:110) (SFB)

• Aktivitetsersättning vid nedsatt arbetsförmåga. Ekonomisk ersättning till personer mellan 19 och 29 år som har en sjukdom eller en funktionsnedsättning som gör att personen inte kan arbeta under minst ett år. Under tiden med aktivitetsersättning kan man få stöd och hjälp med att kunna börja arbeta.
• Aktivitetsersättning vid förlängd skolgång. Ekonomisk ersättning till ungdom med funktionsnedsättning kan få om man behöver längre tid för att bli klar med skolan på grund av en funktionsnedsättning.
• Sjukersättning. Ekonomisk ersättning för personer mellan 19 och 64 år och har en sjukdom eller funktionsnedsättning som gör att personen aldrig kommer att kunna arbeta, varken nu eller i framtiden.
• Bostadstillägg. Ekonomisk ersättning för boende till personer under 65 år med aktivitetsersättning eller sjukersättning och låg inkomst.
• Merkostnadsersättning. Merkostnader till följd av en funktionsnedsättning för exempelvis kostnad upp till högkostnadsskydd för patientavgift, läkemedel och dyrare livsmedel, resa med färdtjänst, sjuk- och behandlingsresor, hemtjänstavgift, kostnad för god man eller privat anlitad städhjälp.
• Ekonomiskt bistånd (SoL).

Fysiska insatser

• Jogging
• Styrketräning
• Yoga
• Dans.

Födointagsinriktade insatser

Föräldraförmågafrämjande insatser

Hjälpmedel (HSL, SL, API, SFB, AML)

Regioner och kommuner delat huvudmannaskap för hjälpmedel.

Hjälpmedelscentraler arbetar med hjälpmedel inom:

Kognition

• Hjälpmedel för att förstå och hantera tid, strukturera och planera, samt för att komma ihåg vad, hur och när något skall göras (minnesstöd). Exempelvis almanackor, kalendrar och planeringssystem, samt ur och klockor. Finns som appar, programvara, i telefoner, på surfplattor med mera.

Läs- och skriv

• Stavningsprogram, textuppläsning, förslag på ord, ordförklaring med mera.

Kommunikation

• Dator med talsyntes, surfplattor/datorer med bilder/piktogram/BLISS, bokstäver
• Samtalsmatta, kommunikationsväst
• Appar och andra mjukvaror
• Bokstavstavla
• Ordkarta
• Manöverkontakter
• Ögonstyrning och ögonpekning
• Mus

Personlig vård

• Hygienhjälpmedel såsom duschpall, träningshjälpmedel, dynor, madrasser, personlyft

Rörelse och förflyttning

• Ortopedtekniska hjälpmedel som ortoser och proteser, förflyttningshjälpmedel som exempelvis manuella och eldrivna rullstolar rullatorer, arbetsstolar, och ramper.

Medicinsk behandling

• TENS, inhalatorer, kylhjälpmedel, nutritionspumpar, syrgaskoncentrator, ventilator, hostmaskin, insulinpump med mera.

Inkontinens

• Absorberande hjälpmedel, kateter, uppsamlingspåsar, stomi

Fritidshjälpmedel

• Cykel, sit-ski, hockeykälke med mera.

Hörselcentraler arbetar med hjälpmedel inom:

Hörsel

• Teckenspråkig litteratur med mera, hörselslingor, hörselhjälpmedel med mera.

Syncentraler arbetar med hjälpmedel inom:

Syn

• Förstoringsprogram, skärmläsningsprogram, inläst litteratur, talböcker, taltidningar, punktskriftsböcker, taktila bilderböcker golvbeläggning vid synnedsättning, DAISY, vit käpp, ledarhund.

Specialpedagogiska skolmyndigheten arbetar med:

• Särskilda pedagogiska hjälpmedel inom skola, förskola, fritidshem och annan pedagogisk verksamhet (SL).

Arbetsförmedlingen och Försäkringskassan ger:

• Bidrag till person med funktionsnedsättning för hjälpmedel som underlättar på arbetsplatsen (API, SFB)
• Bidrag till arbetsgivare för hjälpmedel som underlättar på arbetsplatsen för person med funktionsnedsättning (API).

Arbetsgivare ansvarar för:

• Arbetstekniska hjälpmedel (AML).

Habilitering/Rehabilitering (HSL, SoL, LSS)

Följande kan ingå

• Information om personens funktionsnedsättning.
• Behandling för motorisk och språklig utveckling.
• Behandling, stöd och insatser för psykisk och social utveckling.
• Behandling, stöd och insatser för att utveckla socialt samspel.
• Stöd och utprovning av hjälpmedel för att kunna göra vardagsaktiviteter.
• Råd inför bostadsanpassning och annan anpassning av miljön.
• Samtalsstöd.

Målsättningen är att bibehålla eller utveckla:

• Motorisk förmåga
• Språklig förmåga
• Förmågan att kommunicera
• Social förmåga
• Psykologisk förmåga
• Förmåga att sköta sin vardag.

Exempel på insatser är:

• Allmän och kompletterande kommunikation (AKK) (talsvårigheter) inklusive hjälpmedel för detta
• Seriesamtal
• Social färdighetsträning
• Tydliggörande pedagogik
• EIBI (Early and Intensive Behavorial Intervention) enligt Lovaas
• EarlyBird, föräldrautbildning-inriktad föräldrautbildning för autism
• Föräldrautbildning för beteendeproblematik (PMT - Parent Management Training; The Parent Child Game; Defiant Children; Webster-Stratton; COPE - Community Based Parent Education)
• Föräldrautbildning för språkstörningar (Hanen Program)
• Föräldrautbildning för samspel och beteende (Martemeo; Timjan, Kommunikativ ridterapi)
• Djurassisterad terapi
• Musikterapi.

Inkluderar:

Hjälpmedelscentral

• Kognition, läs- och skriv, kommunikation, personlig vård, rörelse och förflyttning, medicinska behandlingshjälpmedel, inkontinens, fritid

Syncentral

• Synsvaga, gravt synskadade, syn-hörselskadade och dövblinda

Hörsel central/audiologi

• Barndomsdöva, dövblinda, vuxendöva och hörselskadade

Tolkcentral

• Vardagstolkning till barndomsdöva, dövblinda, vuxendöva och hörselskadade
• Teckenspråk, Tecken som stöd – TSS, MHS – mun handsystemet, skrivtolkning.

Kognitiva insatser

• Aktivitetsschema/Dagschema
• Organisatoriska färdigheter
• Att sätta upp mål
• Delad uppmärksamhet/Joint attention.

Kommunikationsinriktade insatser

• Allmän och kompletterande kommunikation (AKK) (talsvårigheter)
• Manuell och kroppsnära: Naturliga reaktioner och signaler (gester, kroppsspråk, mimik); Tecken som AKK (TAKK) (kommunikationssätt för hörande personer med försenad eller avvikande språkutveckling)
• Grafisk: Konkreta föremål; Bilder; Piktogram (bildlika grafiska symboler); BLISS (grafiska symboler); Bokstäver
• Kommunikationsstrategier. PECS (Bildbyte. En AKK-metod som har som syfte att träna in kommunikation för personer vars grundproblematik är att de inte riktar sin kommunikation till andra människor)
• Hjälpmedel (HSL)
• Kommunikationshjälpmedel: Dator med talsyntes, surfplattor/datorer med bilder/piktogram/BLISS, bokstäver; Samtalsmatta, kommunikationsväst; Appar och andra mjukvaror; Bokstavstavla; Ordkarta
• Hjälpmedel för styrning av kommunikationshjälpmedel: Manöverkontakter; Ögonstyrning och ögonpekning; Mus; Med hand
• Svenskt teckenspråk – visuellt, gestuellt (dövhet), taktilt (dövblindhet)) (Den som är döv eller hörselskadad och den som av andra skäl har behov av teckenspråk ges möjlighet att lära sig, utveckla och använda det svenska teckenspråket; Språklag).
• Punktskrift (Blindhet) (ej lagstadgad rättighet att lära, lärs ut i skolan bland annat)
• Syntolkning (blindhet)
• Vardagstolkning (HSL) (tolk till döva, dövblinda och hörselskadade, Tolkcentraler).

Motivationsinriktade insatser

• Motiverande samtal/Motiverande intervju (MI).

Pedagogiska insatser

• Seriesamtal (ritprata)
• Sociala berättelser (Social stories). En i förväg färdigställd instruktion i bild och ord som beskriver ändamålsenligt sätt att bete sig i vardagen, exempelvis gå över ett övergångsställe
• Tydliggörande pedagogik. Genom struktur och visuella konkreta hjälpmedel (TEACCH Treatment and Education of Autistic and related Communication handicapped Children)
• Utbildning. Avseende exempelvis sexualkunskap, fysisk aktivitet, förbättrad egenvård, undvika farliga situationer såsom sexuella trakasserier, för att göra val/välja, psykoedukation.

Personlig assistans (LSS, SFB)

Psykosociala insatser

• Acceptance and Commitment Therapy (ACT)
• Kognitiv beteendeterapi (KBT)
• Självhjälpsgrupper
• Terapi för aggressionshantering (Anger management)

Familjeinriktade insatser

• Stepping Stones Triple P, De otroliga åren, Signpost for Building Better Behaviour Programme, Parent Child Interaction Therapy (PCIT), Parents Plus, familjeterapi, systemisk terapi, Coping Cat.

Sensoriska insatser

• SIT; gungning, rubbning, viktbälten med mera
• Viktvästar
• Bolltäcken
• Snoezelen (sinnesstimulering i ett för ändamålet särskilt utrustat rum).

Stöd från anhöriga/föräldrar/vänner/andra

• Rollmodeller.

Sömnfrämjande insatser

Tekniska insatser (konsumentprodukter)

• Telefoner/Plattor/Datorer
• Internetanvändning inkl. sociala medier
• VR
• Spel såsom WII m-fl.
• Datorprogram
• Teknik för att styra omgivningsmiljö.

Transportrelaterade insatser

• Bilstöd för vuxna (SFB)
• Färdtjänst/Riksfärdtjänst (Lagarna om färdtjänst (1997:736) och riksfärdtjänst (1997:735) (LFT/LRFT).

Övriga hälsorelaterade insatser

• Alkohol/Tobaksprevention
• Diet
• Egenvård
• Hälsodagbok
• Massage
• Mindfullness
• Olycksfallsprevention
• Självskadebeteende – insatser för att förhindra.

Farmakologisk insats

• Läkemedel (Läkemedelslagen (2015:315)).

Medicinska insatser (HSL)

Anhöriga eller andra närstående till personer med funktionsnedsättning

Föräldrar till barn med funktionsnedsättning, barn till föräldrar med funktionsnedsättning, syskon till syskon med funktionsnedsättning, make/maka/partner till person med funktionsnedsättning, andra närstående till person med funktionsnedsättning.

Insatser – exempel

Insatser som påverkar egen hälsa, välmående och fungerande

• Personlig assistans (LSS, SFB)
• Avlösarservice i hemmet (LSS)
• Korttidsvistelse utanför det egna hemmet (LSS)
• Avlösning (SoL)
• Behandling (SoL)
• Föräldrastöd
• Föräldrautbildning exempelvis psykoedukation
• Anhörigbehandlande insats som påverkar egen hälsa, välmående. KBT
• Familjeinriktade insatser. Stepping Stones Triple P, De otroliga åren, Signpost for Building Better Behaviour Programme, Parent Child Interaction Therapy (PCIT), Parents Plus, Barkley´s Parent Training Programme, Parent Management Training (PMT), familjeterapi, systemisk terapi.

Insatser som påverkar föräldraförmåga/stödjande förmåga

Behandling (SoL)

• Föräldrastöd
• Föräldrautbildning
• Familjeassisterade insatser.

Anhörigbehandlande insats som påverkar föräldraförmåga

• KBT
• Familjeinriktade/omgivningsinriktade insatser: Stepping Stones Triple P, De otroliga åren, Signpost for Building Better Behaviour Programme, Parent Child Interaction Therapy (PCIT), Parents Plus, Barkley´s Parent Training Programme, Parent Management Training (PMT), familjeterapi, systemisk terapi
• Omvårdnadsbidrag (SFB). För föräldrar till barn med funktionsnedsättning för omvårdnad och tillsyn som barnet behöver utöver vad som är vanligt för barn i samma ålder utan funktionsnedsättning.
• Rätt till förkortad arbetstid (Föräldraledighetslagen). För förälder med omvårdnadsbidrag finns rätt att förkorta arbetstid med upp till 25 procent, även efter barnet fyllt åtta år
• Kontaktdagar (SFB). För föräldrar till barn under 16 år med funktionsnedsättning som har ett barn som omfattas av LSS. Dagarna finns för förälder ska få ökad kunskap om hur barnet kan stöttas genom utbildning, besök på skolan, deltagande i aktiviteter exempelvis. Ersättning gäller för 10 kontaktdagar per barn och år.
• Bilstöd för barn (SFB). Bilstöd är bidrag till förälder som har ett barn som har väldigt svårt att förflytta sig på grund av en funktionsnedsättning, eller åka allmänna kommunikationer som till exempel buss eller tåg tillsammans med föräldern. Bilstöd är till för att köpa eller anpassa en bil efter barnets behov.
• Habilitering/Rehabilitering (HSL, SoL). Familjeassisterade och familjestödjande insatser.

Insatser som medverkar till anhörigas försörjning

• Merkostnadsersättning (SFB). Ersättning för merkostnader till följd av barnets funktionsnedsättning för exempelvis hälsa, vård, kost, hjälpmedel, resor, anpassade fritidsaktiviteter och leksaker, eller när barnet vårdas på sjukhus en längre tid och du behöver vara där.

Yrkesverksamma

Handläggare, personer med stödjande/rådgivande uppdrag, behandlande personal, personal inom skolan, arbetsgivare med flera.

Arbetsmetoder och arbetsverktyg – exempel

IBIC, ICF, BDI (Becks Depression Inventory), BEP (Brukarenkät psykiska funktionshinder), Beteendeskattning av brukare med funktionsnedsättning, CAN-S (Camberwell Assessment of Need), COPM, FREDA, Katz ADL-index, brukarenkäter, Autonomi insatser.

Rutiner och arbetssätt

• Exempelvis för att säkra barn, ungdomars och vuxna med funktionsnedsättnings rätt att komma till tals och bli lyssnade

Samverkansplattformar, organisation, rutiner samt insatser för samverkan

• Samordningsförbund
• Organisation för samverkan
• Rutiner för samverkan
• Samverkansinsatser. Exempelvis ett personligt ombud (case manager/case management) som är en insats som samordnar vård och omsorg för personer med psykisk funktionsnedsättning. I rehabilitering av hjärnskada benämns det hjärnskadekoordinator.

Utbildning

Arbetstekniska hjälpmedel (AML)

Ekonomiskt stöd och ersättning till arbetsgivare:

• Särskilt högriskskydd (SFB). Arbetsgivare kan få ersättning för sjuklönekostnader om anställd riskerar att ha långa sjukperioder eller riskerar att vara sjuk ofta. Den som är sjuk ofta kan även slippa karensavdragen.
• Lönebidrag (API). Stöd till arbetsgivare som anställer personer med nedsatt arbetsförmåga på grund av funktionsnedsättning
• Bidrag till arbetsgivare för hjälpmedel som underlättar på arbetsplatsen för person med funktionsnedsättning (API).
• Skyddat arbete hos offentlig arbetsgivare, bidrag för lön till arbetsgivaren (API).

Bilaga 3 Funktionsnedsättning, sjukdomsdiagnoser och funktionstillstånd.

Bilaga 4 Litteratursökning

Medline via Ovid 8 June 2017

Cohrane Library via Wiley 19 May 2017

Scopus via Elsevier 8 June 2017

Socindex via ebsco.com 7 April 2017

PsycInfo via ebsco.com 7 April 2017

ERIC via ebsco.com 7 April 2017

Sociological Abstracts, Social Services Abstracts via Proquest 9 May 2017

Academic Search Elite via ebsco.com 8 June 2017

ASSIA via Proquest 5 May 2017

IBSS via Proquest 10 May 2017

Bilaga 5 Inkluderade insatser och arbetsmetoder

Personer med funktionsnedsättning

Insatser per insatsområde

Arbets-, sysselsättnings- och fritidsinriktade insatser

• Arbetsmarknadspolitisk insats SIUS
• Insatser för att underlätta övergång till arbetsliv/transitionsinsatser
• Anställning och stöd/Supported Employment
• Individuell placering och stöd/Individual Placement and Support
• Sensoriska insatser såsom upplevelserum
• Involvering i dagliga aktiviteter
• Daglig verksamhet (LSS)
• Dagverksamhet (SoL)
• Involvering i fritidsaktiviteter.

Autonomirelaterade insatser

• Rådgivning och annat personligt stöd (LSS)
• Rådgivning och stöd (SoL)
• Rutiner och arbetssätt samt förhållningssätt som säkrar barn, ungdomars och vuxna med funktionsnedsättnings rätt att komma till tals och bli lyssnade på samt ges möjligheter att göra val
• Personliga budgetar för att kunna köpa sociala välfärdstjänster (SoL, LSS)
• God man, förvaltare (FB)
• Framtidsfullmakter (LFF).

Beteendeinriktade insatser

• Tillämpad beteendeintervention (TBI)
• Metoder/strategier som bygger på TBI såsom funktionell analys, pivotal responsträning, positivt beteendestöd (PBS) med flera.
• Funktionell kommunikationsträning
• Miljöträning
• Användning av teknik, exempelvis film (video-modelling), för beteendeinlärning.

Boenderelaterade insatser

• Bostadsanpassning (LBB)
• Bostad med särskild service för vuxna eller annan särskilt anpassad bostad enligt LSS)
• Särskilt boende för personer med funktionsnedsättning (SoL)
• Boendestöd (SoL)
• Hemtjänst (SoL)
• Trygghetslarm (SoL)
• Matdistribution (SoL)
• Korttidsboende (SoL).

Delaktighetsfrämjande- och socialt främjande insatser

• Ledsagarservice (LSS, SoL)
• Kontaktperson (LSS) (SoL). Kontaktperson enligt socialtjänstlagen kan beviljas om den enskilde har ett begränsat socialt nätverk, riskerar isolering eller har behov av att bryta isolering.
• Korttidsvistelse utanför det egna hemmet (LSS) Korttidshem, korttidsfamilj, läger
• Korttidstillsyn för skolungdom över 12 år (LSS)
• Social färdighetsträning (Social skills interventions). Insatser som avser att påverka förmågan att kommunicera med andra och utveckla samt bibehålla sociala relationer.

Fysiska insatser

• Jogging
• Styrketräning
• Dans.

Föräldraförmågafrämjande insatser

Kognitiva insatser

• Aktivitetsschema, Organisatoriska färdigheter
• Att sätta upp mål
• Delad uppmärksamhet/Joint attention.

Kommunikationsinriktade insatser

• Naturliga reaktioner och signaler i form av gester, kroppsspråk, mimik
• Teckenspråk – visuellt, gestuellt (dövhet), taktilt (dövblindhet)) (Den som är döv eller hörselskadad och den som av andra skäl har behov av teckenspråk ges möjlighet att lära sig, utveckla och använda det svenska teckenspråket).
• Syntolkning (blindhet).

Motivationsinriktade insatser

• Motiverande samtal/Motiverande intervju (MI).

Pedagogiska insatser

• Seriesamtal (ritprata)
• Sociala berättelser (Social stories). En i förväg färdigställd instruktion i bild och ord som beskriver ändamålsenligt sätt att bete sig i vardagen, exempelvis gå över ett övergångsställe
• Tydliggörande pedagogik. Genom struktur och visuella konkreta hjälpmedel (TEACCH Treatment and Education of Autistic and related Communication handicapped Children)
• Utbildning. Avseende exempelvis sexualkunskap, fysisk aktivitet, förbättrad egenvård, undvika farliga situationer såsom sexuella trakasserier, för att göra val/välja, psykoedukation.

Personlig assistans (LSS, SFB)

Psykosociala insatser

• Acceptance and Commitment Therapy (ACT)
• Kognitiv beteendeterapi (KBT)
• Självhjälpsgrupper
• Terapi för aggressionshantering (Anger management)
• Familjeinriktade insatser
• Stepping Stones Triple P, De otroliga åren, Signpost for Building Better Behaviour Programme, Parent Child Interaction Therapy (PCIT), Parents Plus, familjeterapi, systemisk terapi, Coping Cat.

Sensoriska insatser

• SIT; gungning, rubbning, viktbälten med mera
• Viktvästar
• Bolltäcken
• Snoezelen (sinnesstimulering i ett för ändamålet särskilt utrustat rum).

Stöd från anhöriga/föräldrar/vänner/andra

• Praktisk hjälp, socialt stöd, rollmodeller m. fl.

Transportrelaterade insatser

• Bilstöd för vuxna (SFB)
• Färdtjänst/Riksfärdtjänst (LFT/LRFT).

Andra hälsorelaterade insatser

• Egenvård
• Födointagsinriktade insatser
• Hälsodagbok
• Massage
• Mindfullness
• Olycksfallsprevention
• Självskadebeteende - insatser för att förhindra
• Sömnfrämjande insatser.

Anhöriga eller andra närstående till personer med funktionsnedsättning

Föräldrar eller vårdnadshavare till barn med funktionsnedsättning, barn till föräldrar med funktionsnedsättning, syskon till syskon med funktionsnedsättning, make/maka/partner till person med funktionsnedsättning, andra närstående till person med funktionsnedsättning

Insatser som påverkar anhörigas egen hälsa, välmående och fungerande för sin egen skull.

• Personlig assistans (LSS, SFB)
• Avlösarservice i hemmet (LSS)
• Korttidsvistelse utanför det egna hemmet (LSS)
• Avlösning (SoL)
• Behandling (SoL)
• Föräldrastöd
• Föräldrautbildning exv. Psychoeducation
• Kognitiv beteendeterapi (KBT)
• Familjeinriktade insatser: Stepping Stones Triple P, De otroliga åren, Signpost for Building Better Behaviour Programme, Parent Child Interaction Therapy (PCIT), Parents Plus, Barkley´s Parent Training Programme, Parent Management Training (PMT), familjeterapi, systemisk terapi.

Insatser som påverkar anhörigas föräldraförmåga/stödjande förmåga:

• Behandling (SoL)
• Föräldrastöd
• Föräldrautbildning
• Familjeassisterade insatser
• Kognitiv beteendeterapi (KBT)
• Familjeinriktade/omgivningsinriktade insatser: Stepping Stones Triple P, De otroliga åren, Signpost for Building Better Behaviour Programme, Parent Child Interaction Therapy (PCIT), Parents Plus, Barkley´s Parent Training Programme, Parent Management Training (PMT), familjeterapi, systemisk terapi.

Yrkesverksamma inom funktionshinderområdet

Handläggare, personer med stödjande/rådgivande uppdrag, behandlande personal, vård- och omsorgspersonal

Arbetsmetoder och arbetsverktyg

• IBIC, ICF, BDI (Becks Depression Inventory), BEP (Brukarenkät psykiska funktionshinder), Beteendeskattning av brukare med funktionsnedsättning, CAN-S (Camberwell Assessment of Need), COPM, FREDA, Katz ADL-index, brukarenkäter
• Autonomiinsatser
• Rutiner och arbetssätt
• Samverkansplattformar, organisation, rutiner samt insatser för samverkan
• Samordningsförbund
• Organisation för samverkan
• Rutiner för samverkan
• Samverkansinsatser.

Bilaga 6 Exkluderade populationer, insatser och arbetsmetoder

Systematiska översikter som studerat behandlingar, riktade till personer med diagnoserna stroke, depression och, förvärvad hjärnskada, som huvudsakligen tillhör hälso- och sjukvårdens ansvarsområden och hälso- och sjukvårdslagen (HSL) är exkluderade. Då sådan behandling huvudsakligen tillhör hälso- och sjukvårdens ansvarsområden. Sådana insatser kan vara längre kognitiva insatser såsom minnesträning, kognitiv beteendeterapi samt konstterapi, musikterapi, och djurassisterad terapi. I de fall det handlat om insatser för personer med dessa diagnoser som genomförts inom ramen för de lagstiftningar som beskrivs i Faktaruta 1.2 är de dock inkluderade.

Vidare är systematiska översikter som studerat medicinska insatser såsom kirurgiska ingrepp (t.ex. Cochleaimplantat), metoder och instrument för att ställa medicinska diagnoser eller fastställa tillstånd, förekomst (prevalens) av diagnoser och tillstånd samt all form av farmakologisk behandling exkluderade då även de områdena tillhör hälso- och sjukvårdsområdet. När det gäller farmakologisk behandling har vi exkluderat de systematiska översikter där farmakologisk behandling utgjort den största andelen av de insatser som studerats (Exempelvis 45 % farmakologiska insatser, 35 % psykosociala insatser, 20 % andra insatser). Systematiska översikter som utvärderat insatser relaterade till missbruk av alkohol eller narkotika är exkluderade liksom insatser kopplade till enbart diet i relation till hälsa.

Systematiska översikter som studerat upplevelse eller erfarenhet av att leva med en diagnos, ett tillstånd eller funktionsnedsättning liksom bakgrundsfaktorer för olika tillstånd och diagnoser är exkluderade.

Detta gäller även allmänna och universella insatser såsom:

• Allmänna delaktighetsfrämjande insatser
• Tillgängliga medier, allmänna krav. Lättläst material; Punktskrift; Taltidningar; Talböcker
• Samhällsintegrering
• Allmänna insatser för att motverka diskriminering och stigma (DL)
• Allmänna krav och insatser i bostäder och byggd miljö (PBL)
• Allmänna krav på tillgängliga transporter (LHK)
• Attityd – och beteendepåverkande insatser
• Universell utformning
• Systematiska översikter som studerat ekonomiska ersättningar (SFB) såsom exempelvis:
• Aktivitetsersättning vid nedsatt arbetsförmåga och förlängd skolgång
• Sjukersättning
• Bostadstillägg
• Merkostnadsersättning.

När det gäller arbetsliv är systematiska översikter som behandlat arbetsmiljörelaterade och andra ekonomiska insatser till arbetsgivare exkluderade. Detsamma gäller översikter som handlat om nedanstående arbetsmarknadspolitiska insatser:

• Personligt biträde. För person med funktionsnedsättning som behöver hjälp med vissa arbetsuppgifter kan personligt biträde beviljas där arbetsgivaren kompenseras ekonomiskt
• Pedagogiskt stöd vid deltagande i utbildning via Arbetsförmedlingen
• Arbete på Samhall
• Individuellt anpassat stöd när person med funktionsnedsättning söker arbete
• Vägledning för att övergång från skolan till arbetslivet ska bli så smidig som möjlig
• Psykosocialt anpassningsstöd
• Arbetslivsinriktad rehabilitering
• Bidrag till person med funktionsnedsättning för hjälpmedel som underlättar på arbetsplatsen.
• Skyddat arbete hos offentlig arbetsgivare
• Lönebidrag
• Stöd till arbetsgivare som anställer personer med nedsatt arbetsförmåga på grund av funktionsnedsättning
• Bidrag till arbetsgivare för hjälpmedel som underlättar på arbetsplatsen för person med funktionsnedsättning.

Systematiska översikter som studerat insatser som faller inom ramen för habiliteringens och hjälpmedelsområdets ansvarsområden är exkluderade. Systematiska översikter avseende vardagstolkning, det vill säga tolk till döva, dövblinda och hörselskadade är även de exkluderade.

Habiliteringens insatser gäller behandling för motorisk utveckling, språklig förmåga, tidiga insatser riktade till barn, samt barns lek och vänskapsrelationer. De sistnämnda kan också ingå i förskolans och skolans uppdragsområde. Insatser såsom konduktiv pedagogik och lekterapi är därmed exkluderade. Detsamma gäller systematiska översikter som handlat om kommunikationsinriktade insatser i form av:

• Allmän och kompletterande kommunikation (AKK)
• Tecken som AKK (TAKK)
• Grafisk kommunikation såsom:
• Konkreta föremål
• Bilder
• Piktogram (bildlika grafiska symboler)
• BLISS (grafiska symboler)
• Bokstäver
• Kommunikationsstrategier såsom:
• PECS (Bildbyte. En AKK-metod som syftar till att träna kommunikation för personer som har kommunikativa svårigheter)
• Systematiska översikter som handlar om hjälpmedelsinsatser är exkluderade. Sådana är:
• Kognitionshjälpmedel såsom hjälpmedel för att förstå och hantera tid, strukturera och planera, samt för att komma ihåg vad, hur och när något skall göras (minnesstöd).
• Kommunikationshjälpmedel: Dator med talsyntes, surfplattor/datorer med bilder/piktogram/BLISS/bokstäver; Samtalsmatta, kommunikationsväst; Appar och andra mjukvaror; Bokstavstavla; Ordkarta
• Hjälpmedel för styrning av kommunikationshjälpmedel såsom: Manöverkontakter; Ögonstyrning och ögonpekning; Mus
• Läs- och skrivhjälpmedel såsom: Stavningsprogram, textuppläsning, förslag på ord, ordförklaring med mera.
• Hjälpmedel för personlig vård såsom: Hygienhjälpmedel såsom duschpall, träningshjälpmedel, dynor, madrasser, personlyft med flera.
• Hjälpmedel för rörelse och förflyttning såsom: Ortopedtekniska hjälpmedel som ortoser och proteser, förflyttningshjälpmedel som exempelvis manuella och eldrivna rullstolar rullatorer, arbetsstolar, och ramper.
• Medicinska behandlingshjälpmedel såsom: TENS, inhalatorer, kylhjälpmedel, nutritionspumpar, syrgaskoncentrator, ventilator, hostmaskin, insulinpump med mera.
• Hjälpmedel vid inkontinens: Absorberande hjälpmedel, kateter, uppsamlingspåsar, stomi med mera.
• Fritidshjälpmedel: Cykel, sit-ski, hockeykälke med mera
• Hörsel: Teckenspråkig litteratur med mera, hörselslingor, hörselhjälpmedel med mera.
• Syn: Förstoringsprogram, skärmläsningsprogram, inläst litteratur, talböcker, taltidningar, punktskriftsböcker, taktila bilderböcker golvbeläggning vid synnedsättning, DAISY, vit käpp, ledarhund
• Särskilda pedagogiska hjälpmedel inom skola, förskola, fritidshem och annan pedagogisk verksamhet.
• Arbetstekniska hjälpmedel till personer med funktionsnedsättning.

Även tekniska insatser som kan utgöra konsumentprodukter är exkluderade:

• Telefoner/Plattor/Datorer
• Internetanvändning inkl. sociala medier
• VR
• Spel såsom WII med flera
• Datorprogram
• Teknik för att styra omgivningsmiljö.

Bilaga 7 Kvalitetsbedömningsmall baserad på AMSTAR-mallen

Steg 1. Är kriterier för vad som ska ingå tydliga? (PICO, inklusions- och exklusionskriterier skall vara angivet). Sökningen matchar populationen och interventionen och är väl genomförd och dokumenterad så att den kan återskapas. (AMSTAR 1 och 3).

Steg 2. Studiernas relevans har granskats av två oberoende personer på abstrakt och fulltextnivå och ett konsensusförfarande bör finnas beskrivet. De inkluderade studierna finns angivna. (AMSTAR 2 och 5).

Steg 3. Inkluderade studier är kvalitetsgranskade och kriterier för kvalitetsnivå ska finnas beskriven. Kvalitén, karakteristika och resultat på de respektive inkluderade studierna framgår tydligt och finns dokumenterade (AMSTAR 6 och 7).

Steg 4. Studierna har vägts samman i metaanalys eller metasyntes på ett korrekt sätt om detta var lämpligt, i annat fall beskrivits narrativt (AMSTAR 9).

Steg 5. Resultaten är evidensgraderade eller beskrivna i slutsatsen där hänsyn har tagits till studiernas kvalitet. I tillämpliga fall bör de även undersökt överförbarhet, samstämmighet, precision och risk för publikationsbias (AMSTAR 8 och 10).

Steg 6. Exkluderade studier finns dokumenterade, likaså författarnas jävsförhållanden. Protokoll för översikten finns. Författarna har angett om alla typer av publikationer omfattades av litteratursökningen. (AMSTAR 1, 4, 5 och 11).

Bilaga 9 Beskrivning av de domäner och omgivningsfaktorer som finns i Internationella klassifikationen av funktionstillstånd, funktionshinder och hälsa (ICF) [304].

Domän

Lärande och att tillämpa kunskap

Målinriktade sinnesupplevelser

Se, lyssna, annat målinriktat utnyttjande av sinnesintryck, andra specificerade och ospecificerade målinriktade sinnesupplevelser.

Exempel: Titta på ett sportevenemang eller på barn som leker, lyssna på radio, musik eller en föreläsning, beröra och känna ytstruktur, smaka på sötsaker eller lukta på blommor.

Grundläggande lärande

Härma, repetera, lära sig läsa, lära sig skriva, lära sig räkna och beräkna, förvärva färdigheter, annat specificerat och ospecificerat grundläggande lärande.

Exempel: Efterlikna en gest, ett ljud eller bokstäverna i ett alfabet, räkna med tiotal eller recitera en dikt, på ett flytande och korrekt sätt läsa skriftligt material, inklusive punktskrift, såsom att känna igen tecken och bokstäver, att uttala ord med korrekt uttal och förstå ord och uttryck, framställa symboler som representerar ljud, ord eller fraser för att uttrycka mening, inklusive att skriva punktskrift, såsom att stava riktigt och att använda korrekt grammatik, använda matematiska tecken för addition och subtraktion och att tillämpa korrekta matematiska beräkningar vid problemlösning, att förvärva färdighet att hantera matbestick, verktyg eller spela spel, till exempel schack.

Att tillämpa kunskap

Fokusera uppmärksamhet, tänka, läsa, skriva, räkna och beräkna, lösa problem, fatta beslut, tillämpa kunskap.

Exempel; Filtrera bort störande ljud, hitta på en historia, bevisa ett teorem, leka med idéer, komma på idéer, förmedla, fundera eller reflektera, fatta och tolka skrivet språk, t.ex. böcker, instruktioner eller tidningar i text eller punktskrift, i syfte att skaffa sig allmän kunskap eller specifik information, producera en skriftlig redogörelse av händelser eller idéer eller att skriva ett brev, beräkna summan av tre tal eller att beräkna resultatet av att dividera ett tal med ett annat, identifiera och analysera frågor, utveckla möjliga lösningar, utvärdera tänkbara effekter av lösningar och genomföra en vald lösning såsom att lösa en konflikt mellan två personer, välja och köpa en specifik sak eller att besluta att göra och även genomföra en uppgift bland flera uppgifter som behöver genomföras.

Allmänna uppgifter och krav

Att företa enstaka uppgift, att företa mångfaldiga uppgifter, genomföra dagliga rutiner, hantera stress/kriser och andra psykologiska krav.

Exempel: Att förbereda, påbörja och ordna den tid och det rum som krävs för en enkel uppgift, att utföra en enkel uppgift med en enstaka huvudsaklig komponent såsom att läsa en bok, skriva ett brev eller bädda sin säng, att förbereda, påbörja och ordna tid och rum för en enstaka sammansatt uppgift, att genomföra en sammansatt uppgift med mer än en komponent, som kan genomföras i följd eller samtidigt såsom möblera sitt hem eller att fullfölja en läxa i skolan, Att förbereda, påbörja och ordna tid och rum för en enkel eller sammansatt uppgift och att hantera och utföra uppgiften på egen hand och utan stöd av andra, Att förbereda, påbörja och ordna tid och rum för en enstaka uppgift, enkel eller sammansatt, att hantera och utföra uppgiften tillsammans med personer som är involverade i några eller i alla steg i uppgiften. Att hantera sin egen aktivitetsnivå, att hantera förändringar i daglig rutin, att hantera sin tid samt anpassa sig till tid. Hantera, ansvar, kriser, stress, behärska sitt beteende, att följa rutiner.

Kommunikation

Att kommunicera – att vara mottagare

Ta emot talade meddelanden, icke-verbala meddelanden, meddelanden på teckenspråk, skrivna meddelanden, meddelande på andra och ospecificerade sätt.

Exempel: Att begripa ordagranna och dolda innebörder i talade meddelanden såsom att förstå att ett uttalande påstår ett faktum eller är ett idiomatiskt uttryck, att begripa ordagranna eller dolda innebörder i meddelanden som överbringas genom gester, symboler och teckningar såsom att förstå att ett barn är trött när det gnuggar sig i ögonen eller att varnings ljud betyder att det brinner, att begripa innebörden som förmedlas genom ansiktsuttryck, handrörelser eller tecken, kroppsställning och andra former av kroppsspråk, att begripa innebörden av offentliga tecken och symboler såsom trafikmärken, varningssymboler, musikaliska eller vetenskapliga teckensystem och ikoner, Att ta emot och begripa ordagrann och dold innebörd i meddelanden på teckenspråk, att begripa ordagrann och dold innebörd i meddelanden som är överbringade genom skrivet språk (innefattande punktskrift).

Att kommunicera – att vara sändare

Uttrycka sig genom icke-verbala meddelanden, meddelanden på teckenspråk, skriva meddelanden, genom andra specificerade och ospecificerade meddelanden.

Exempel: Att använda gester, symboler och teckningar för att uttrycka meddelanden såsom att skaka på huvudet för att antyda bristande instämmande eller att teckna en bild eller diagram för att uttrycka ett faktum eller en komplex idé, mimik (t.ex. att le, rynka pannan och skaka på huvudet), arm- och handrörelser samt kroppsställning såsom att omfamna för att antyda en varm känsla, använda tecken och symboler (t.ex. ikoner, Blissbordssymboler, vetenskapliga och matematiska symboler) och symboliska teckensystem såsom musikaliska noter för att uttrycka en melodi, rita, teckna, måla, skissa, göra diagram eller bilder eller använda fotografier, att uttrycka ordagrann och dold innebörd genom teckenspråk, att förmedla ordagrann och dold innebörd i meddelanden som uttrycks genom skriftspråk såsom att skriva ett inbjudningsbrev.

Konversation och användning av kommunikationsutrustningar och kommunikationstekniker

Konversation, diskussion, använda kommunikationsutrustningar och kommunikationstekniker.

Exempel: Att starta, hålla igång och avsluta en konversation eller diskussion såsom samtal om vädret, introducera ett samtalsämne, ställa frågor, debattera.

Att använda telefoner eller annan utrustning, såsom fax eller telexmaskiner, text- och bildtelefoner som kommunikationsmedel.

Att använda utrustning för att skriva, såsom skrivmaskiner, datorer och punktskriftsmaskiner som medel för kommunikation

Att genomföra handlingar och uppgifter som involverar alternativa tekniker för att kommunicera, såsom läppavläsning.

Förflyttning

Ändra och bibehålla kroppsställning

Att ändra grundläggande kroppsställning, bibehålla en kroppsställning, förflytta sig själv.

Bära, flytta och hantera föremål

Att lyfta och bära föremål, flytta föremål med hjälp av benen, handens finmotoriska användning, användning av hand och arm.

Gå och röra sig omkring

Att gå, röra sig omkring på olika sätt, röra sig omkring på olika platser, förflytta sig med hjälp av utrustning.

Förflytta sig med transporthjälpmedel

Att använda transportmedel, vara förare, rida på djur för transport.

Personlig vård

Att tvätta sig, kroppsvård, sköta toalettbehov, klä sig, äta dricka, sköta sin egen hälsa.

Exempel: Använda vatten och lämpliga material och metoder för att bli ren och torr såsom att bada, duscha, tvätta händer och fötter, ansikte och hår och att torka sig med handduk.

Vård av hud, tänder, hår, finger- och tånaglar, att kontrollera urinering, avföring och ta hand om menstruation, att ta på och av kläder och skor och att välja lämplig klädsel

Äta mat som serveras, att föra maten till munnen och konsumera den på ett kulturellt acceptabelt sätt, skära eller bryta maten i bitar, öppna flaskor och burkar, använda matbestick, äta sina måltider till fest och vardags.

Att fatta tag i en dryck som serveras, föra den till munnen och konsumera den på ett kulturellt acceptabelt sätt såsom att blanda, röra och hälla upp dryck för att dricka, öppna flaskor och burkar, dricka genom sugrör eller rinnande vatten från en kran eller källa; bröstuppfödning.

Att tillförsäkra sig fysisk bekvämlighet, hälsa och fysiskt och psykiskt välbefinnande såsom att upprätthålla en balanserad diet, lämplig nivå av fysisk aktivitet, hålla sig varm eller kall, undvika hälsorisker, ha säkra sexualvanor såsom att använda kondom, bli vaccinerad och genomgå regelbundna hälsokontroller, följa medicinska och hälsoråd.

Hemliv

Att skaffa förnödenheter

Att skaffa bostad, varor och tjänster, och förnödenheter.

Hushållsgöromål

Att bereda måltider, hushållsarbete, hushållsgöromål.

Att ta hand om hushållsföremål och att bistå andra

Att ta hand om hemmets föremål, att bistå andra.

Exempel: Köpa bostad, hyra bostad, möblera bostad, handla, laga mat, tvätta, städa, använda hushållsapparater, avlägsna avfall, göra i ordning sovplatser, laga kläder, underhålla möbler och hjälpmedel, ta hand om växter och djur, samt att hjälpa andra tvätta sig, förflytta sig, kommunicera, bereda måltider, sköta sin hälsa.

Mellanmänskliga interaktioner och relationer

Allmänna mellanmänskliga interaktioner

Grundläggande och sammansatta mellanmänskliga interaktioner. Sociala signaler, att bygga upp och avsluta relationer. interagera i överensstämmelse med sociala regler med mera

Särskilda mellanmänskliga relationer

Att ha kontakt med okända personer, formella relationer, informella sociala relationer, familjerelationer, vänner, intima relationer såsom äktenskap, sexuella relationer.

Viktiga livsområden

Utbildning

Informell utbildning, förskoleutbildning, skolutbildning, yrkesutbildning, högre utbildning, annan utbildning.

Arbete och sysselsättning

Lärlingsskap (arbetsförberedelse), att skaffa, behålla och sluta ett arbete, betald sysselsättning, obetald sysselsättning.

Ekonomiskt liv

Grundläggande och komplexa ekonomiska transaktioner, ekonomisk självförsörjning.

Samhällsgemenskap, socialt och medborgerligt liv

Samhällsgemenskap

Engagera sig i samhällsgemenskap

Exempel: Engagemang i frivilligorganisationer, lokala föreningar, sociala ceremonier såsom giftermål.

Rekreation och fritid

Engagemang i lek, fritidssysselsättning.

Exempel: sport, program för fysisk träning, gå på konstutställning, museer, bio, teater, läsa, spela musikinstrument, fritidsresor.

Religion och andlighet

Engagemang i religiösa eller andliga aktiviteter, organisationer och utövande för självförverkligande.

Mänskliga rättigheter

Åtnjutande av mänskliga rättigheter, rätten till självbestämmande eller autonomi/Agency.

Politiskt liv och medborgarskap

Engagemang i medborgerligt socialt, politiskt och statligt liv.

Exempel: Att rösta, skydd mot diskriminering

Produkter och teknik

Produkter, teknik eller substanser för egen konsumtion och eget bruk i dagliga livet.

Exempel: Mat och läkemedel, kläder, proteser, ortoshjälpmedel, teknik för att styra omgivningsmiljön, bussar, bilar, rullstolar, syn- och hörselhjälpmedel, kommunikationshjälpmedel, böcker, datorprogram, skidor, anpassade fritidshjälpmedel, ramper, hörselslingor, skyltar, golvbeläggning vid synnedsättning med mera.

Naturmiljö och mänskligt skapade miljöförändringar

Levande eller döda element i den naturliga eller fysiska omgivningen och komponenter i denna omgivning som har förändrats av människor liksom även befolkningsegenskaper i denna miljö.

Exempel: Fysisk geografi, befolkningstäthet, flora och fauna, temperatur, fuktighet, nederbörd, vind, naturkatastrofer, naturkatastrofer och mänskligt orsakade katastrofer, ljus, tidsrelaterade förändringar, ljud, vibration, luftkvalitet.

Personligt stöd och personliga relationer

Människor eller djur som ger praktiskt fysiskt eller emotionellt stöd, uppfostran, skydd och hjälp och som har relationer till andra personer, i deras hem, på arbetsplatsen, skolan eller vid lek eller i andra avseenden av de dagliga aktiviteterna.

Exempel: Närfamilj, storfamilj eller utvidgad familj, vänner, bekanta, kamrater, kollegor, grannar och personer i umgänget, människor i maktpositioner, människor i underordnade positioner, personliga vårdgivare och personliga assistenter, okända människor, husdjur, yrkesutövare inom hälso- och sjukvård, andra yrkesutövare.

Attityder

Attityder i form av observerbara konsekvenser av seder, bruk, ideologier, värden, normer, uppfattningar om verkligheten och religiösa trosföreställningar.

Exempel: Personliga attityder hos nära familjemedlemmar, den utvidgade familjen, vänner, bekanta, kamrater, kollegor, grannar och personer i umgängeskretsen.

Personliga attityder hos personer i maktpositioner och hos personer i underordnade ställningar.

Personliga attityder hos personliga vårdgivare och personliga assistenter.

Personliga attityder hos okända människor.

Personliga attityder hos yrkesutövare inom hälso- och sjukvården, och hos andra yrkesutövare.

Samhälleliga attityder.

Sociala normer, konventioner och ideologier.

Service, tjänster, system, och policys

Service och tjänster som utformats inom olika samhällssektorer erbjuder bidrag, organiserade program och verksamheter som är formgivna för att möta individuella behov. Standarder, lagstiftning, policys.

Exempel: Service, tjänster, system och policys för produktion av konsumtionsvaror, arkitektur och konstruktion, planering av öppna områden, bostäder, allmänna nyttigheter, kommunikation, transport, beskydd av medborgare.

Service, tjänster, system och policys gällande lagreglering, sammanslutningar och organisationer, socialförsäkring, för allmänna sociala stödinsatser, inom hälsovård, för utbildning och yrkesförberedelse samt arbete och sysselsättning.

Politiska tjänster, system och policys.

Bilaga 10 Referenslista exkluderade artiklar

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• Efficacy, effectiveness and security of the chelation therapy for the treatment of autistic children (Structured abstract). Health Technology Assessment Database 2005.
• Mobile video communication for the deaf - assessment of user benefits (Structured abstract). Health Technology Assessment Database 2005.
• Cognitive rehabilitation for traumatic brain injury in adults (Structured abstract). Health Technology Assessment Database 2008.
• Special report: early intensive behavioral intervention based on applied behavior analysis among children with autism spectrum disorders (Structured abstract). Health Technology Assessment Database 2008.
• Cochlear implants for children and adults with severe to profound deafness (Structured abstract). Health Technology Assessment Database 2009.
• Special report: early intensive behavioral intervention based on applied behavior analysis among children with autism spectrum disorders (Project record). Health Technology Assessment Database 2011.
• Clinical digest. Early interventions with cognitive behavioural therapy could delay schizophrenia. Nurs Stand. 2013;27:15.
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• Special report: early intensive behavioral intervention and other behavioral interventions for autism spectrum disorder (Structured abstract). Health Technology Assessment Database 2015.
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