Rev Psiquiatr Salud Ment (Barc.). 2013;6(3):109---120

www.elsevier.es/saludmental

ORIGINAL ARTICLE

Borderline Intellectual Functioning: Consensus and good practiceguidelines�,��

Luis Salvador-Carullaa,b,c, Juan Carlos García-Gutiérrezd,Mencía Ruiz Gutiérrez-Colosíac, Josep Artigas-Pallarèse,f, José García Ibáneza,c,Joan González Pérezg, Margarida Nadal Plac, Francisco Aguilera Inésa,c,Sofia Isush, Josep Maria Cereza i, Miriam Poolej, Guillermo Portero Lazcanok,Patricio Monzónl, Marta Leivam, Mara Parelladam, Katia García Nonell f,Andreu Martínez i Hernándezn, Eugenia Rigauf, Rafael Martínez-Leala,o,∗

a Unidad de Investigación en Discapacidad Intelectual y Trastornos del Desarrollo (UNIVIDD), Fundació Villablanca, IISPV,CIBERSAM, Reus, Spainb Departamento de Neurociencias, Facultad de Medicina, Universidad de Cádiz, Cádiz, Spainc AEPDI-AEECRM, Asociación Espanola de Profesionales en Discapacidad Intelectual, Madrid, Spaind Unidad de Salud Mental, Universidad de Cádiz, Hospital Universitario de Puerto Real, Cádiz, Spaine Unidad de Neuropediatría, Hospital de Sabadell, Corporació Sanitària Parc Taulí, Sabadell, Spainf Centre de mèdic PSYNCRON, Sabadell, Spaing Asociación Catalana Nabiu (ACNabiu), Inserción laboral de personas borderline en las administraciones públicas, Barcelona,Spainh Departamento de Pedagogía y Psicología, Universidad de Lleida, Lleida, Spaini CEE Esperanza, Lleida, Spainj Fundación FUNPRODAMI, Madrid, Spaink Clínica Médico Forense de Bilbao, Instituto Vasco de Medicina Legal, Bilbao, Spainl Fundación Aéquitas, Cádiz, Spainm Unidad de Adolescentes, Departamento de Psiquiatría, Hospital General Universitario Gregorio Maranón, Madrid, Spainn Departament d’Interior, Generalitat de Catalunya, Barcelona, Spaino Departament de Psicologia, Universitat Rovira i Virgili, Tarragona, Spain

Received 8 August 2011; accepted 17 December 2012Available online 11 April 2013

KEYWORDSBorderlineIntellectualFunctioning;

AbstractIntroduction: The Borderline Intellectual Functioning (BIF) is conceptualised as the frontierthat delimits ‘‘normal’’ intellectual functioning from intellectual disability (IQ 71---85). In spiteof its magnitude, its prevalence cannot be quantified and its diagnosis has not yet been defined.

� Please cite this article as: Salvador-Carulla L, et al. Funcionamiento intelectual límite: guía de consenso y buenas prácticas. Rev PsiquiatrSalud Ment (Barc.). 2013;6:109---20.

�� Luis Salvador Carulla is the president of the working group for the Classification of Intellectual Developmental Disorders that reportsto the WHO for the Revision of the Classification of Behaviour and Mental Disorders of the ICD-10. The statements of this article correspondto the authors’ point of view and are not the WHO official perspective or policy.

∗ Corresponding author.E-mail address: martinezr@peremata.com (R. Martínez-Leal).

2173-5050/$ – see front matter © 2011 SEP y SEPB. Published by Elsevier España, S.L. All rights reserved.

110 L. Salvador-Carulla et al.

Borderlineintelligence;Intellectualdisability;Practice guidelines

Objectives: To elaborate a conceptual framework and to establish consensus guidelines.Method: A mixed qualitative methodology, including frame analysis and nominal groups tech-niques, was used. The literature was extensively reviewed in evidence based medical databases,scientific publications, and the grey literature. This information was studied and a framingdocument was prepared.Results: Scientific publications covering BIF are scarce. The term that yields a bigger numberof results is ‘‘Borderline Intelligence’’. The Working Group detected a number of areas in whichconsensus was needed and wrote a consensus document covering the conclusions of the expertsand the framing document.Conclusions: It is a priority to reach an international consensus about the BIF construct andits operative criteria, as well as to develop specific tools for screening and diagnosis. It is alsonecessary to define criteria that enable its incidence and prevalence. To know what interven-tions are the most efficient, and what are the needs of this population, is vital to implementan integral model of care centred on the individual.© 2011 SEP y SEPB. Published by Elsevier España, S.L. All rights reserved.

PALABRAS CLAVEFuncionamientointelectual límite;Borderline;Inteligencia;Discapacidadintelectual;Guías prácticas

Funcionamiento intelectual límite: guía de consenso y buenas prácticas

ResumenIntroducción: El funcionamiento intelectual límite (FIL) se conceptualiza actualmente como labarrera que separa el funcionamiento intelectual «normal» de la discapacidad intelectual (CI 71-85). A pesar de su magnitud, su prevalencia no puede ser cuantificada y no se ha operativizadosu diagnóstico.Objetivos: Elaborar un marco conceptual para el FIL y establecer directrices de consenso quepermitan la aplicación de una atención integral centrada en la persona.Metodología: Se utilizó una metodología mixta cualitativa que combinaba un análisis del marcoconceptual con el desarrollo de grupos nominales. Se realizó una revisión bibliográfica extensivaen bases de datos de evidencia médica, publicaciones científicas y literatura gris. Se estudió lainformación encontrada y se redactó un documento de marco conceptual sobre el FIL.Resultados: Las publicaciones centradas en el colectivo de personas con FIL son escasas. Eltérmino que mayor número de publicaciones arrojó fue «Borderline Intelligence». Se detectaronuna serie de temas sobre los que era necesario alcanzar un consenso y se redactó un documentocon las conclusiones del grupo de trabajo.Conclusiones: Es necesario establecer un consenso a nivel internacional sobre el constructo delFIL y sus criterios operativos, y desarrollar instrumentos específicos de detección y diagnóstico.También es necesario elaborar criterios que permitan calcular su incidencia y prevalencia. Saberqué intervenciones son las más adecuadas y cuáles son las necesidades de atención que pre-senta este colectivo es de vital importancia para implementar un modelo de atención integralcentrado en la persona.© 2011 SEP y SEPB. Publicado por Elsevier España, S.L. Todos los derechos reservados.

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ntroduction

‘Borderline Intellectual Functioning’’ (BIF) is an extremelyomplex clinical entity, which has barely been studied. Inact, there is not even a minimum consensus in the scien-ific community on what we mean when we speak of BIF andn its relationship to other developmental disorders.1,2 Thisack of taxonomic framework should be considered in theurrent debate over ‘‘mental retardation’’ or ‘‘intellectualisability’’ (ID), where there are 2 apparently contradictoryositions represented by the World Psychiatric Associa-

ion (WPA) and the American Association on Intellectualnd Developmental Disabilities (AAIDD).3 The WPA consid-rs that ID is a meta-syndrome analogous to the concept ofementia in the context of neurodevelopmental disorders

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hat should continue to be coded in the Internationallassification of Diseases (ICD)4; however, the AAIDD andany national and international bodies consider that this

ntity is a disability and should consequently be coded inhe International Classification of Functioning (ICF) insteadf in the ICD.5 This is a leading-edge issue, given theoming revision of the ICD (ICD-11) and of the Unitedtates Diagnostic and Statistical Manual of Mental DisordersDSM-5).

The problems of taxonomy and terminology are evenreater in the case of BIF than in other clinical conditions.

n the bibliography in English terms such as ‘‘Borderlinentellectual Functioning’’, ‘‘Subaverage Intellectual Func-ioning’’, ‘‘Borderline Mental Retardation’’, ‘‘Borderlinentellectual Capacity’’ and/or ‘‘Borderline Learning

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Borderline Intellectual Functioning: Consensus and good pra

Disability’’ have been used more or less indiscriminately.This lack of terminological definition stems from the factthat these days BIF is not included as a diagnostic code inthe DSM-IV-TR, the ICD-10 or the ICF.6---8 In the DSM-IV-TR,Borderline Intellectual Capacity’’ is mentioned in passingas an intellectual quotient (IQ) range between 1 and2 standard deviations below average (70---84), but it isuncoded in this system and is compared to the residualICD system diagnostic code R41.8 (ICD-10). However, codeR41.8 actually refers to ‘‘other symptoms and signs thatimply cognitive functions and ‘apperception’ or becomingaware’’, a totally non-specific code that covers aspects asdifferent as awareness of disease and intelligence.

The lack of terminological consensus and its absence inthe main diagnostic classifications make it especially diffi-cult to calculate the prevalence of BIF among the generalpopulation. If we consider the normal IQ distribution, thispopulation group should represent at least 13.6% of thetotal; in fact, different studies9,10 place the problem in arange lying between 12% and 18% of the population. In thissense, the data from the Spanish survey on disability, per-sonal autonomy and situations of dependence (EDAD-2008 inSpanish) are discouraging.11 This survey improved the infor-mation obtained in the previous survey (EDDES, 1999),12

because it separated the information corresponding to BIFand mild ID, which had been appeared accumulated togetherin the previous survey. However, the EDAD-2009 survey sim-ply confirmed the lack of visibility and assessment for thiscollective. That survey indicated that there were 11,600individuals with BIF. The impossibility of that fact becomesevident if you analyse the figures for mild ID (24,700), mod-erate ID (52,800), and severe and profound ID (47,000). Froma Gaussian perspective of intelligence, these figures wouldclearly be erroneous, given that there could not be moreindividuals with severe and profound ID than with mild ID;at the same time, the figures would be an example of thelack of rigour that often characterises the collection of infor-mation on ID and BIF.

Consequently, BIF turns out to be an invisible clinicalentity. Despite its magnitude, its prevalence cannot bequantified, its diagnosis has not been implemented (so itdoes not appear in current diagnostic systems) and thereare no eligibility criteria to ensure explicit access to socialor health services, protections and benefits when they areneeded. In the same way as patients having mild ID, indi-viduals with BIF represent a significant percentage of thepopulation and require a considerable amount of supportand attention at different moments in their lives.5 However,the scientific literature ignores this population, just as thespecialised services for ID and the services for developmen-tal disorders do.13,14

To progress in developing an international consensus inthis field, the Catalan association Nabiu (ACNabiu) initiatedthe CONFIL project in 2007. This project brought together aset of professionals from different areas with the follow-ing goals: (1) provide the field of BIF knowledge with aconceptual framework within the group of lifelong develop-mental problems, and from a perspective of comprehensive

attention centred on the individual; and (2) establish guide-lines of consensus on BIF in Catalonia. The result wasthe development of a conceptual reference framework onthis health condition that would permit later creation of

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guidelines 111

esearch in this field and the development of a frame-ork for comprehensive attention for BIF (public health,ducational, work and legal). In this article, we presenthe process of consensus and summarise the conclusionseached in the health area by the CONFIL group. The com-lete documentation can be consulted in the following link:ttp://tinyurl.com/5vvx4v9.

ethodology

o build the framework for the base of BIF knowledge, anpproximation derived from the frame analysis generallymployed in social research has been used.15 The usage ofonceptual frame analysis methods along with the processesf consensus is especially useful for studying and formingew diagnostic concepts.16,17 In this case, we decided tose this methodology because there had been no priorttempts to implement and classify this health construct.he process that we followed can be seen in Fig. 1.

tep 1 (conceptual framework)

o manage an insufficiently-defined health construct (BIF)hat, in addition, is related to a poorly categorised attentionystem (intellectual development disorders), it was neces-ary to study the current conceptual framework to know theontext, terminology and content.

First of all, the scientific literature on BIF was system-tically reviewed on Medline, PsycIinfo, TRIPdatabase,long with a manual review of the 10 leading jour-als in the area of psychology and social sciences inN-RECS between 1996 and 20 [stet] (later updatedn 2011). The following entries were used for the review:‘Borderline Intellectual Functioning’’, ‘‘Subaverage Intel-ectual Functioning’’, ‘‘Borderline Mental Retardation’’,‘Borderline Intellectual Capacity’’, ‘‘Borderline IQ’’nd ‘‘Borderline Learning Disability’’. Likewise, the cur-ent legislation and policies related to the subject wereeviewed, including the information provided by fam-ly groups, users and associations. Finally, a conceptualramework document was written, in which all the rel-vant bibliography and the sources from it came werencluded.

tep 2 (working group-nominal panel)

nominal group consisting of 6 members and a rapporteuras formed. The panel functioned following an adaptationf the application of this health methodology18 that turnedut to be very useful in attempts to reach consensusesn extremely complex issues in which the information wasncomplete. This group reviewed the conceptual frameworkocument and prepared a list of key subjects in each of theIF spheres in which it was considered necessary to evaluatehe evidence and reach a consensus.

Correspondingly, a group of 6 experts was set up. Thisroup performed a critical review of the first draft consensus

ocument and of the successive drafts and participated inriting the final consensus document.

The final consensus group consisted of psychiatrists, psy-hologists, educators, notaries and members of the Catalan

112 L. Salvador-Carulla et al.

Establishment of theworking group

Establishment of a referencegroup to supervise consulting

the drafts

Review of the literatureConsultation of the grey literature

Consideration of current legislation andpolicies related to the subject

Search for information in family groups,users, associations...

Determination of the objective and contentof the consensus document. Review of the

relevant evidence. Determination of processesfor incorporating the opinions of userfederations and prototypical cases

Remittance of the draft tothe reference group.

Period of consultation

Review and revision thedocument according to the

comments given in the periodof consultation

Publication and disseminationof the consensus document

Evaluation ofthe impact

Process of review and updatingIdentification of new research

on the subjectConsideration of the challenges

presented by using the documentat a practical level

Selection of the subject andprocess of Scooping

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Figure 1 Framing analysis. Process of co

ssociation ACNabiu. All the members of the consensusroup were professionals who had prior experience in thereatment, attention or work with individuals that hadIF.

tep 3 (preparation of the consensus document)

hree work meetings were held in which the members ofhe nominal group participated. In the first meeting, thebjectives and the content of the consensus document werestablished and the key topics were decided. The draft wasent to the group of experts and a consultation period of

months was established. In this period, the document waseviewed and modified according to the comments giveny the group of experts. Once the period of consultationas over, the final document was published and its content

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us and preparation of the final document.

as disseminated. Finally, the impact of the publication wasvaluated.

esults

eview of the literature

ublications that focus on BIF are rare. The termshat yielded the greatest number of results were‘Borderline Intelligence’’, ‘‘Borderline Intellectual Func-ioning’’, ‘‘Borderline IQ’’ and ‘‘Borderline Mental Retarda-ion’’. The terms ‘‘Borderline Capacity’’ and ‘‘Borderline

earning Disability’’ produced only 2 results each, whilehe term ‘‘Subaverage Intellectual’’ yielded only 1. Eveno, the great majority of the studies found did not treatIF directly; and, in many of the cases, the studies only

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Borderline Intellectual Functioning: Consensus and good pra

mentioned the relationship between BIF and some of thegenetic or metabolic syndromes in passing, or the studieswere duplicated in the different searches. Faced with thislack of extensive scientific evidence, most of the conclu-sions presented in this article were reached by consensus.Consequently, they represent the lowest level of evidencepossible and their level of recommendation should thereforebe taken with caution.

Key topics

In the conceptual framework document, several key topicson which a consensus was necessary were proposed: Defini-tion and implementation of the concept of BIF; prevalenceand diagnostic process; early detection and attention;model for attention and intervention; comorbidity, educa-tion and BIF; inclusion and employability; and training andresearch. The CONFIL 2007 group published a consensusdocument treating all these topics more extensively19 andagreed to a statement that summarises the main points ofthe consensus document (Table 1).

Definition and implementation of BorderlineIntellectual Functioning

The CONFIL 2007 consensus group defined BIF a ‘‘health

meta-condition that requires specific public health, edu-cation and legal attention’’. It is characterised by diversecognitive dysfunctions that are associated with an IQbetween 71 and 85, and which determine a deficit in the

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Table 1 Points on the Borderline Intellectual Functioning (BIF) st

POINT 1 BIF is a ‘‘health meta-condition that requires specharacterised by various cognitive dysfunctions awhich determines a deficit in the individual’s funand limitation of social participation

POINT 2 The child population with BIF is more vulnerable

challenge of achieving early detection, a psychoplearning potential in these cases

POINT 3 Mental health problems are more frequent in BIFpsychopathological assessment is necessary in thecognitive profile and to the profile of functioning

POINT 4 In the stage of childhood-adolescence, there is a

that allow restriction of a group of individuals thaeducational process like the majority of boys and

POINT 5 Individuals with BIF require some support that faccases, specific health attention

POINT 6 The difficulties of legal and administrative accessothers) supported by the population with BIF cau

POINT 7 The objectives of early detection, assessment anincorporated in health, social, educational, labouprinciples of justice, equality and diversity

POINT 8 Encouraging research on the different aspects of

social, educational, labour and legal perspectivesPOINT 9 Training on BIF for the professionals in the variouPOINT 10 Territorial spaces of interdepartmental coordinat

knowledge among professionals, users, participanlabour, social action, the legal system, etc.)

guidelines 113

erson’s functioning both in the restriction of their activi-ies and in the limitation of their social participation, withhe following descriptors:

. BIF is not a syndrome, nor a disorder, nor a disease. It is aheterogeneous grouping of specific neurodevelopmentalsyndromes, disorders or diseases and possibly of extremevariations of normality.

. BIF can be defined as a ‘‘health meta-condition thatrequires specific public health attention’’.

. The cognitive deficits that underlie overall IQ assessmentare heterogeneous, so cognitive assessment of the indi-viduals with BIF should not be limited to IQ measurement.

. Not all the individuals with an IQ between 71 and 85have limitations in activity and restrictions in participa-tion. Consequently, a specific assessment of capacitiesand functioning is needed to make a diagnosis of BIF.

In Descriptor ‘‘1’’, it was decided to incorporate theerm ‘‘normality’’ in spite of the conceptual difficulty inpplying it to BIF,20 given that we still do not have suffi-ient evidence to distinguish the cases of BIF clearly relatedo an alteration in neurodevelopment that require specificttention because of it, from the cases that correspond toariations of normality and do not need such attention. Thisescriptor requires BIF to be largely associated with neu-

odevelopmental disorders,1 but the provisional choice wasade, faced with a lack of greater level of evidence, to

nclude this denomination in the descriptor and not in theefinition.

atement prepared by the consensus group.

cific public health, educational and legal attention’’. It isssociated with an intellectual quotient between 71 and 85,ctioning with respect to both restriction in activities

than the general population, which is why we pose theathological assessment and assessment of the specific

than in the general population, which is why a specificse cases. This assessment needs to be incorporated into the

as part of the BIF assessmentneed to define the concept of BIF on the basis of criteriat, without having intellectual incapacity, cannot follow the

girls of their age and social environmentilitates school, work and social adaptation and, in some

ibility (e.g., eligibility for certificate of disability andse a need for help that has to be correctedd attention for individuals with BIF must be specificallyr and legal spheres, to develop a society based on the

BIF is needed, from the health perspective as well as the

s spheres that are involved is requiredion must be promoted, along with the transmission ofts and the various sectors involved (e.g., health, education,

1 L. Salvador-Carulla et al.

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Table 2 Tests proposed by the CONFIL 2007 consensusgroup for assessing intellectual quotient according to the agerange in which they are applicable.

Age

Verbal intelligence testsBSID. Bayley Scales of InfantDevelopment

0---2.5

MSCA. McCarthy Scales of Children’sAbilities

2.5---8.5

WISC-IV. Wechsler Intelligence Scalefor Children --- IV

6---16.9

WPPSI. Wechsler Preschool andPrimary Scale of Intelligence

4---6.5

K-ABC. Kaufman Assessment Batteryfor Children

2.5---12.5

K-BIT. Kaufman Brief Intelligence Test 4---90

Nonverbal intelligence testsRaven’s Progressive Matrices 12---65TONI-2. Test of NonverbalIntelligence, 2nd Edition

5---85.9

Leiter-R. Leiter InternationalPerformance Scale, Revised

2---20.9

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Descriptor ‘‘2’’ defines the term of ‘‘meta-condition’’.his is a word derived from the concept of ‘‘condition ofealth’’7 and is a significant choice, because it representhe assumption that BIF is not a mere problem of functioninghat should be classified in the ICF or not coded at all, it is

set of ‘‘conditions of health’’ that should consequently belassified in the ICD-10.

Descriptor ‘‘3’’ indicates the cognitive deficits of BIFre heterogeneous and can be selective. Consequently,easuring the general intelligence is a necessary but insuffi-

ient condition in the neuropsychological assessment of BIF,ecause specific deficits in language, writing and reading,alculation, visual-spatial abilities and executive functionsan alter the individual’s functioning at school and work andn social settings.

Descriptor ‘‘4’’ indicates that the presence of an IQetween 1 and 2 standard deviations below the average71---85) is not a sufficient condition for diagnosis of BIF,iven that not all of the individuals in this range haveimitations in activities and restrictions on participation.21

ust as in the diagnosis of ID, borderline functioning in theQ has to be associated with a social, work and academicunctioning sufficiently intense to limit the subject’sctivity and restrict social their participation. Likewise,

deterioration of general functioning does not involve aIF diagnosis unless it is associated with an IQ between 71nd 85. The selection of the range 71---85 lies above theD threshold adopted by the WHO (IQ: 69). The consensusroup preferred to choose the cut-off point indicated in theSM-IV-TR. The adverb ‘‘generally’’ was incorporated intohe definition to refer to the IQ range until we have greatervidence and/or international consensus.

revalence and diagnostic processf Borderline Intellectual Functioning

s we have previously commented, this is a frequent healthondition that, nonetheless, has barely been the object ofttention for the public health system. If we look exclu-ively at the normal distribution of IQ, this populationroup would represent 13.6% of the total11; other esti-ates place the problem in a range between 12% and

8% of the population.19 If we take as a reference thechool population with problems of academic performancessociated with this IQ range, and we bear in mind a pos-ible improvement with age if part of this group adapts tooorly qualified work environments in adulthood, it can bestimated that the population affected would be around%. From a conservative perspective, the consensus groupstimated that the population in this IQ range could beround 3% of the population, or some 1,350,000 people inpain. If we evaluate only the group of individuals with alear need for public health attention in this group, the‘floor’’ would be placed at 1%, or 450,000 people. Even theost conservative estimates indicate that BIF is a hiddenroblem that has to be put in the focus of public atten-ion.

In Fig. 2, you can see the diagnostic process proposedy the CONFIL 2007 consensus group illustrated. As in anyther assessment, using a complete clinical history is rec-mmended, focusing especially in developmental aspects,

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detailed clinical examination and observation and theertinent biomedical investigations. Secondly, and althought is not the only or the most important consideration,Q needs to be established by administering both verbalnd non-verbal intelligence tests (Table 2). This assessmentf the intelligence level for the individual with BIF needso be complemented by a complete cognitive assessmentf various cognitive functions that will make it possi-le to obtain information as to the subject’s weak andtrong points. It has recently been proposed that, givenhe heterogeneity and multi-causation of BIF, an impor-ant number of subject probably have altered executiveunctions,2 understanding these functions as the group ofbilities needed to organise, plan and direct our behaviourowards some objective flexibly and efficiently.22 Conse-uently, we are going to find alterations in capacities for:enerating behaviours with a purpose, solving problems in

planned and strategic manner, paying attention to differ-nt aspects of a problem simultaneously, guide attentionith flexibility, inhibit spontaneous tendencies that lead torror, retaining in working memory the information requiredor an action, and capturing what is essential in a complexituation.

Next, assessing the presence of a typable neurodevel-pmental disorder (TNDD) is recommended. All the TNDDsave in common the fact that a cognitive dysfunction underl-es them that gives rise to symptoms with a certain degreef specificity; in addition, BIF is frequently associated witharious TNDDs.1

Finally, and given the high psychiatric comorbidity foundn BIF, assessing the presence of behaviour, anxiety, affectivend psychotic disorders is recommended.

Borderline Intellectual Functioning: Consensus and good practice guidelines 115

CLINICAL HISTORY

Aspects of development, examination and clinical observation, biomedical investigation

ESTABLISHING IQ

COGNITIVE ASSESSMENT

BORDERLINE INTELLECTUAL FUNCTIONINGBIF?

SPECIFIC DEVELOPMENTAL DISORDERS

GENERALISED NEURODEVELOPMENTAL DISORDERS

COMORBIDITY: DISORDERS OF BEHAVIOUR, ANXIETY, DEPRESSION, PSYCHOSIS......

Verbal and/or manipulative tests

Language, Attention, Memory, Visual-spatial Function, Executive Function, Behavioural and Emotional Aspects

roup

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The challenges of early detectionand attention

The possibility of carrying out early detection in cases ofBIF and being able to implement the appropriate inter-ventions as soon as possible is impossible during earlychildhood. This is because neither the knowledge nor thetools required to do so have been available to date. How-ever, the challenge of early detection for BIF cases shouldbe of great importance, for several reasons. The suspicionof the condition in the first years of life would allow us

to reduce the barriers to access to services and, conse-quently, to implement interventions whose objective wasto prevent negative evolution of the case (such as, forexample, early stimulation programmes). There is evidence

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to detect and diagnose Borderline Intellectual Functioning.

hat interactions with the environment in the first devel-pmental stages directly influence brain development.23,24

his implies that early interventions could have the poten-ial to modify developmental patterns, improve educationalerformance and obtain improvements in social function-ng. Early interventions have been shown to be effectiveuring the first stages of disorders such as autism,25 Downyndrome,26 children with disabilities in general or at riskf suffering from disability,27 and in attention to prema-ure infants.28 Providing support resources early on canrevent situation of academic failure that could lead

o disorders of an emotional type or behaviour disor-ers.

However, early detection represents today a challenge,iven that there are no visible features to identify a

1 L. Salvador-Carulla et al.

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Table 3 Neurodevelopmental disorders most commonlyassociated with Borderline Intellectual Functioning.

Generalised developmental disordersHigh-functioning autismAsperger syndromeNon-specific generalised developmental disorder

Specific developmental disordersDyslexiaDyscalculiaMathematics learning disorderNonverbal learning disorder

Other developmental disordersFoetal Alcohol SyndromeFragile X SyndromeVelocardiofacial SyndromePrader-Willi SyndromeWilliams SyndromeAttention Deficit and Hyperactivity Disorder

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hild with BIF, nor are there discriminating behaviouralhenotypes. The CONFIL 2007 group feels that developingiagnostic and screening batteries for BIF and developingpecific training programmes for professionals is an urgenteed. However, at present it is difficult to imagine diagnosticnd screening batteries for BIF different from the develop-ental batteries used to diagnosis overall developmentalelay, a concept that is used for ages below 5---6 years. Itould therefore be necessary to use the existing batter-

es systematically in situations in which there is a suspicionf BIF. These batteries could be complemented with morepecific neuropsychological examinations and with measuresocused on behavioural abilities. In short, and despite theifficulties, early detection should be specifically incor-orated in health, social and school spheres, to make itossible to ensure that these individuals are integrated inociety according to principles of justice, equality and diver-ity.

odel for attention and intervention

he CONFIL 2007 consensus group backs the creation of ter-itorial spaces for interdepartmental coordination amongifferent sectors of the administration to ensure the trans-ission of knowledge among professionals, users and the

arious sectors involved (e.g., health, education, work,ocial action, legal system, etc.). Diagnostic suspicion ofIF cases can stem from paediatricians and paediatric nurs-

ng staff in primary care, from professionals in kindergartensnd schools, and from the parents themselves. Once the sus-ected diagnosis is established, the child should be referredo specialised services offered by mental health attentionor children, which will in turn be connected for develop-ental pathologies with the neuropaediatric services and

arly attention services.The intervention requires collaboration among the dif-

erent professionals and services from the first momentnd a fluid contact among the health services and theocial and educational resources. Later on, in adult-ood, participation will be needed by the work andiving arrangement spheres and, sometimes, the legalystem. The interventions should not be distinguish-ble from those used for developmental disorders andhey should be directed aimed at BIF. They shouldnclude, among others: programmes with the mediationf the parents, interventions of communication sup-ort, psychotherapeutic interventions when behaviouralr emotional disorders are present, curriculum adapta-ion in the educational process, programmes for access tohe work world and community residential programmes.he possibility of applying pharmacological interventionshould be assessed when there are comorbid disordersuch as affective, anxiety, hyperactivity, insomnia disor-ers, etc. In situations of comorbidity, an effort muste made so that these individuals can receive psy-hotherapeutic attention,29,30 given that different studiesave shown that they are more or less often treated

ith psychiatric drugs (including antipsychotics) withoutn appropriate prior case history and diagnosis, withhe possibility of presenting adverse effects, some ofhich are more frequent in this population than in

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eneral populations (for example, greater extrapyramidalide effects).31

omorbidity

he disorders most frequently related with BIF are set outn Table 3.

As for psychiatric comorbidity, a study30 consisting of aopulation survey of more than 8000 adults, among whichhere was a percentage of 12% of BIF, showed that these indi-iduals have more emotional, substance use, personality,daptation and social problems than the study individualsithout BIF. In addition, the BIF population received morerug treatments and made higher use of medical serviceshan the general population. This same pattern is repeatedn the child population; a very recent study32 concludedhat children with BIF contributed disproportionately to therevalence of mental disorders in the general child popula-ion.

In contrast to the groups with moderate or severe ID, theistribution of psychopathology that appears in BIF is similaro that of the general population general and we find greaterrequency of anxiety and behavioural disorders.33,34

The fact that some of the mental disorders appear con-urrently with a borderline intelligence range is of greatmportance in the prognosis. This is because it adds a furthereature of severity to the evolution. This has been specif-cally documented for a population with schizophrenia in

study35 that compared adults with schizophrenia and BIFgainst adults with schizophrenia and normal intelligence;he study showed that the first group had worse quality ofife, more severe psychotic symptoms and worse generalunctioning.

Children and adolescents with BIF are thus a popula-

ion at risk, vulnerable, of growing accumulating differentevelopmental mental and social problems. In a study34 thatollowed adolescents with BIF, it was found that the factorsost related with evolution in terms of psychopathology

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were (in addition to difficulties in social competency) thedeficit in daily life abilities, health problems and negativeadverse events.

Behavioural disorders appear in 30% of the children withmild BIF or ID. The clear relationship that exists betweenlow verbal intellectual abilities and antisocial behaviouris highly influenced by socio-cultural deprivation.36 Thereis also a very clear relationship, one that is very difficultto separate, of the influence of low-normal intelligence,low scholastic performance and abandoning school atearly ages on later criminal behaviour. This relation-ship is mediated to a good degree by the presence ofhyperactivity.37

Individuals with persistent behavioural disorders, whichbegan early, have an average of 8---12 IQ points below that ofthe average general population. The presence of problemsin the parents, which affect their educational capabilities,together with other risk factors, has an interactive, poten-tiating effect on the appearance of behavioural problems.In a longitudinal study38 carried out in London, 400 childrenwere followed from 8 to 40 years old; low performance insecondary school and low non-verbal IQ were found to be themain factors of risk for the development of later antisocialbehaviour.

There seem to be some gender differences with respectto the relationship between intelligence and behaviourproblems. In a general population, a negative relationshipbetween intelligence and behaviour problems was found inboys; however, this relationship was positive in girls, andthe higher the intelligence, the greater the behaviour prob-lems they presented.39 These differences were also seenin the case of specific reading disorders, which appeareddirectly associated with behaviour problems in girls but itseemed that, in boys, the association was mediated by stu-dent absenteeism.38

Psychopathology in the parents, having single parents,stressful events and other individual factors such as tem-perament or the existence of associated hyperactivity havean exponential effect in combination with low intelli-gence. The effect of various associated risk factors onintelligence is usually greater than the simple sum of theeffect of the individual factors. That is to say, the pos-sible effect on intelligence that parental psychopathologycombined with single parenthood could have is consider-ably greater than the sum of the effect of these 2 factorsseparately.34

Education and Borderline IntellectualFunctioning

Under the label BIF, you can find students with totally dif-ferent trajectories, having their low scholastic performancein common40: problems with reading, writing or calculation,due to a low level of understanding, poor verbal fluency, dif-ficulties in the reasoning and symbolisation processes, poorattention and concentration, or lack of self-esteem and per-

sonal initiative. These characteristics, along with the lackof a clear diagnosis and of early detection, lead to manystudents who fall into ‘‘academic failure’’ being in realityindividuals with undetected BIF.

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guidelines 117

The majority of these students are not detected to bendividuals with BIF until they begin to attend school; theyan even reach the end of primary school, when they are2 years old, without being diagnosed because their appar-nt normality makes the problem difficult to detect.ith the arrival of adolescence, the distances with their

lassmates in the acquisition of academic competenciesncrease notably, and imbalances in their behaviour canrise. These individuals can begin to feel rejected sociallyecause of their inadaptation to free time, to affec-ive relationships, to work or to independent living. Thebsence of a diagnosis deprives them of possible rightsnd help to make it possible to face a difficult presentnd a dark future weighed down with rather problem-tic prognoses.41 However, it is also true that, with theecessary support, especially from classmates, their devel-pment can follow more normal pathways. It is importantor individuals with BIF attending school to be kept inrdinary educational centres, given that various studies42

ave shown that the individuals achieve better academicerformance and greater social competence if this hap-ens.

The CONFIL 2007 consensus group prepared a series ofecommendation that they hope will be useful to improvehe current educational attention for individuals with BIF:1) systematic collaboration among professionals in theepartments of Education and Health; (2) greater atten-ion to the collective with intellectual limitations at theoments of transition between life stages; (3) creation

f educational protocols adapted for attention to stu-ents with behavioural disorders; (4) preparation of anndividualised educational plan; (5) presence of a specificutor in each educational stage; and (6) destruction ofhe myths surrounding the IQ figure as the single, exclu-ive parameter for diagnosing BIF, along the same linesn that IQ in and of itself is not enough for ID diagno-is.

nclusion, employability and Borderlinentellectual Functioning

he end of the school stage represents a new challengeor the individual with BIF to face. Access to the workorld takes longer for these people and, if they manage

o enter it, they will do so having to face all the difficul-ies that we have described up to this point. Employments a determining factor for improving the quality of life ofndividuals with BIF. On the one hand, these individuals doot receive social aid, given that they are recognised aspt for work, but on the other hand, they have a series ofifficulties and limitations in their functioning that makesccess to the labour market difficult. In fact, BIF is not con-eptualised in workers’ statutes, so going from exclusiono inclusion is extremely hard. Consequently, the gener-lised acknowledgement that employment is the key toocial insertion in the current society43 acquires a spe-ial meaning in the population of individuals with BIF.To

e able to carry out a complete, reliable assessment ofhe level of employability of the individuals with BIF, onehould bear in mind the complete personal history, the IQ,he use of validated instruments for measuring adaptive

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apacities, the collection of information from people in thendividual’s surroundings and the assessment of the envi-onment. The following instruments can be useful to assessndividuals’ adaptive capacities: Checklist of Adaptive Liv-ng Skills, Adaptive Living Skills Curriculum and Inventory oflient and Agency Planning.44---46

Lastly, if the political powers would design and imple-ent appropriate policies, this could eliminate the obstacles

hat prevent the integration of individuals with BIF intoork and social environments. It would also favour the nor-alisation of the general social status of individuals withIF.

raining and research

raining the professionals responsible for attending individ-als with BIF is an especially relevant topic. As we mentionedn the introduction, BIF has been shown to be an unseenondition; these people simply do not exist in a great manyreas and services for attention, whether health, social orducational. There is a need for a great labour of dissem-nation and of training for the teaching professionals andor the psycho-social assessment, so that the school can beonverted into a space where children and adolescents withIF are detected and the support programmes needed cane applied. The same is true of paediatricians, nurses andental health teams, so that these individuals are detected

s early as possible and for the attention programmes to bepecific and structured.

Research requires a consensus at the international leveln the construct of BIF and the establishment of widely-ccepted operative criteria. From that point on, it woulde possible to work on developing specific instruments foretection and diagnosis, and on the establishment of criteriahat would make it possible to calculate the incidence andrevalence of BIF. We also need answers as to which inter-entions are most appropriate and effective in the attentiono individuals with BIF. We have to know what the needs forttention that these individuals present are, and whetherhey can be seen in already-existing services with effective-ess, just as has been occurring up until now. Lastly, basicnd genetic research could clarify part of the etiological fac-ors associated with this condition, while cost studies couldhow the true magnitude and repercussion of this problemn society.

orderline Intellectual Functioning in theontext of a system of comprehensivettention

onsidering all of the above, the CONFIL 2007 group pro-osed a model of comprehensive, holistic attention, seeingo both public health aspects and educational, work andegal-administrative aspects of the individuals with BIF inhich any non-included needs exist. The proposed model

hould consider both negative health aspects (illness andisabilities, risk factors and subjective experience of ill-

ess) as well as positive aspects (well-being, recovery,nternal and external protection factors, and subjectivexperience of health and quality of life). It should alsoonsider the assessment throughout the individual’s life

L. Salvador-Carulla et al.

ycle, with special attention in the critical life tran-itions (e.g., the steps from childhood to adolescence,rom adolescence to adult life, the transition to a job,tc.). Such a model makes it possible to create opportu-ities in the school and in the community; in addition,n contrast to the classic individual planning, it allowsransferring control and responsibility to the individualshemselves.

A system of integrated attention has to include notnly the individuals with BIF, but also their families. Itust be guaranteed in all geographical areas, promoting

he appearance of territorial spaces of interdepartmentaloordination. These spaces could encourage coordina-ion, communication, collaboration and knowledge transfermong professionals, users, participants and the various sec-ors involved (e.g., health, education, labour, social action,he legal system, etc.).

Finally, a model of comprehensive attention for individ-als BIF needs to follow the focus on social inclusion ints individual, family and community dimensions. An indi-idual with BIF should be able to have access to theirights and opportunities just like any other citizen, avoid-ng situations of discrimination and giving rise to policies ofquality.

thical disclosures

rotection of human and animal subjects. The authorseclare that no experiments on human beings or on animalsere performed for this investigation.

onfidentiality of data. The authors declare that no patientata appear in this article.

ight to privacy and informed consent. The authorseclare that no patient data appear in this article.

unding

his study was funded by theDepartment of Healthf the Catalan government (Generalitat de Catalunya)ith the approval of the CONFIL 1, 2, 3 and CONFIL 2010rojects, by the Obra Social Caja Madrid and by Asociaciónequitas.

The final version of this work was possible thankso the POMONA-ESPANA project (PI12/01237), funded byhe Health Research Fund of Instituto de Salud CarlosII.

onflict of interests

he authors have no conflict of interests to declare.

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