REVIEW

CURRENT
OPINION Borderline intellectual functioning: an update
Stephen Greenspan

Purpose of review
Borderline intellectual functioning (BIF) is a descriptive v-code that is often used, especially in forensic
settings, as if it were a full-fledged disorder. Various historical and other aspects of this classification are
reviewed, and commentary is made on the question of whether to upgrade BIF to a regular psychiatric
category, or to eliminate it by folding it into an already recently expanded category of intellectual
developmental disorder (IDD).
Recent findings
Full-scale intelligence quotient (IQ) is an outmoded concept that is decreasingly being used. For example,
DSM-5 states that measures of ‘executive functioning’ (reasoning, planning, consequential thinking,
attention, self-regulation, and so on) are often more meaningful that full-scale IQ as diagnostic indicators of
IDD. Even the definition of BIF in DSM-5 no longer specifies an IQ score range.
Summary
BIF is a descriptive v-code (rather than a typical psychiatric category), which started out as a sub-type of
IDD (formerly mental retardation or intellectual disability) but morphed into its current status when the IQ
ceiling for IDD was changed from minus one standard deviation (85) to minus two standard deviations
(70). It has been suggested that, as people with BIF often have adjustment problems, the BIF category be
elevated to the status of a formal psychiatric disorder. In this article, a contrary opinion is expressed,
namely that the BIF category be dropped.
Keywords
intellectual disability, intelligence, learning disability

INTRODUCTION scores. In fact, BIF no longer has specific defining

People labeled borderline intellectual functioning
(BIF) have intelligence quotient (IQ) scores and
other indices of cognitive functioning that are sig-
nificantly low, but not so low as to cause them to be
&&
labeled IDD [1 ,2]. In DSM-IV-TR, BIF was defined
by an IQ range that is at least one standard deviation
(SD) below the population mean, but above the level
approximately minus two SDs required for someone
to qualify for a diagnosis of IDD. As the population
mean for IQ is arbitrarily set at 100, and the SD is
set at 15, this means that someone with BIF under
DSM-IV-TR would have had a full-scale IQ falling
between approximately 71 and 85 [3]. As deter-
mined by the so-called ‘normal’ curve, an IQ of
70 places one at the second percentile, whereas an
IQ of 85 places one at the sixteenth percentile. Thus,
14 percentage of the population (the difference
between 16 and 2) was eligible to be labeled BIF.
This would make BIF potentially the most prevalent
of all psychiatric labels, if it were routinely assigned
to all those with qualifying IQ scores, which, for-
tunately it was not [4]. In DSM-5, there was a move
away from a strict specification of BIF by full-scale IQ
language [5]. Possible reasons are discussed later.
As with the other psychiatric category using the
prefix ‘borderline’ (i.e. borderline personality dis-
order, or BPD), the term BIF indicates that a person
likely has problems in daily functioning, but not so
severe that they incapacitate him or her from play-
ing age-typical social roles such as work or inde-
pendent living [6]. A difference is that BPD is by
itself a billable psychiatric category, whereas BIF, as a
so-called v-code (found at the back of DSM-5, as was
previously the case with DSM-IV) is a descriptor
indicating a problem or risk factor rather than a
formal disorder, and thus is not billable. For some-
one with BIF to be eligible for psychiatric or disabil-
ity benefits, he or she would have to also have
another label [7]. As BIF is often the result of
University of Connecticut, Littleton, Colorado, USA
Correspondence to Stephen Greenspan, University of Connecticut,
Littleton, CO, USA. Tel: +1 303 948 3452;
e-mail: stephen.greenspan@gmail.com
Curr Opin Psychiatry 2017, 30:113–122
DOI:10.1097/YCO.0000000000000317

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Neurodevelopmental disorders
KEY POINTS
 Borderline intellectual functioning (IQ range of 71–85)
is a V code diagnosis in DSM-5 with no requirement for
deficits in adaptive functioning.
 With the elimination of IQ ranges to define severity of
intellectual deficits in DSM-5, the diagnosis of
borderline intellectual functioning as a V code
diagnosis is problematic.
 In forensic settings, a finding of borderline intellectual
functioning, unlike that of intellectual disability, makes
the defendant eligible for the death penalty.
 People with borderline intellectual deficits, such as
those with a diagnosis of FASD, have adaptive
functioning deficits, and should be considered
intellectually disabled based on their deficits despite IQ
scores over 75.
 It is proposed that the borderline intellectual deficit
category be eliminated and the IQ range increased for
IDD in DSM-5 because people with borderline
intellectual functioning, especially those with FASD,
have deficits in adaptive functioning that meet
DSM-5 criteria.
brain-affecting developmental (e.g. fetal alcohol
spectrum disorder), educational (e.g., learning dis-
ability) or adult-onset (e.g. traumatic brain injury)
conditions, or places one at risk for other disorders,
the v-code designation does not necessarily pose an
insuperable obstacle to a person receiving needed
services.
&
In addition, there are some [8 ] who believe that
BIF should be recognized as a substantial disorder in
its own right. The present study responds to this
suggestion, starting with a consideration of the
complicated history of developments in related
disorders (particularly IDD) and related fields
(particularly intelligence). Finally, confounding
sociocultural issues, such as poverty will be con-
sidered, ending with the question: should BIF be
elevated to the status of a full-fledged disorder, or be
dropped altogether, perhaps with a full or partial
folding into another disorder, such as a possibly
expanded IDD category?
BORDERLINE INTELLECTUAL
FUNCTIONING AND RELATED DISORDERS
In considering the current and future status of BIF, it
is important to examine it in relation to other
diagnostic categories. Three categories will be briefly
discussed: intellectual developmental disorder,
learning disability, and brain syndromes (with fetal
alcohol spectrum disorder as an exemplar).
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INTELLECTUAL DISABILITY AND
BORDERLINE INTELLECTUAL
FUNCTIONING
Until 1973 [9], BIF was a subcategory of IDD, referred
to in DSM-III and DSM-IV, as ‘borderline mental
retardation’. The 1961 classification manual for the
American Association on Intellectual and Develop-
mental Disability (an organization formerly known
by other names) posited five levels of IDD severity:
borderline, mild, moderate, severe, and profound,
all defined by IQ SD ranges: borderline (71–85),
mild (56–70), moderate (41–55), severe (26–40),
and profound (25 or below). This classification
scheme was adopted in 1952 by the American Psy-
chiatric Association in DSM-II [10], and subsequent
DSM editions have largely followed the AAIDD for-
mulation, with the partial exception of DSM-5
which diverged from AAIDD in some respects [11].
As mentioned, until 1973 people diagnosed
with Borderline IDD had IQ scores that were one
SD below the population mean, that is, from the 2nd
to 16th percentile of the population. Thus, setting
the ceiling for IDD at 85 was obviously too high, as
the conventional wisdom (not necessarily empiri-
cally established) was that the prevalence rate for
IDD was the least intelligent three percentage of the
population [12]. A second diagnostic criterion was
introduced in the 1961 AAIDD manual: adaptive
behavior (termed adaptive functioning in DSM
manuals), which was intended to ensure that IDD
was based not just on IQ but also on problems of
daily functioning. This poorly defined construct (for
which initially there were no standardized measure-
ment instruments) was in theory supposed to bring
the incidence of IDD down to something approach-
ing the hypothesized three percentage. But as this
second defining construct was ignored for years
&
[13 ], the result was overdiagnosis of IDD, particu-
larly in school settings and particularly with poor
and minority students (many of whom had IQ
scores in the borderline range but who lacked evi-
dence of behavior or brain impairments). Thus,
including a category of Borderline IDD created a
problem of ‘false positives’, that is, people diagnosed
with IDD who should not have been [14].
The solution adopted by AAIDD in its 1973
manual revision (followed by later DSM manuals)
was to drop the borderline IDD subcategory, thus
transforming the disorder category of borderline
IDD into the descriptive v-category of BIF, and
establishing the upper IQ ceiling of ‘mild’ IDD (a
misnomer, as the disability can be substantial) at 70,
or the second percentile. This was obviously too low,
as the belief had been that the prevalence of IDD was
three percentage, and dropping the IQ ceiling that
low now created a problem of ‘false negatives’
Volume 30  Number 2  March 2017

(people wrongly classified as non-IDD). As a
consequence, many individuals with brain-based
syndromes (for which mean IQs often are in the
mid or high 70s) were now prevented from receiving
services and supports that were badly needed. As
documented in a study of adults formerly labeled
with borderline IDD who now were labeled with BIF,
a great many of these individuals (some of them
formerly institutionalized) now faced great diffi-
culty surviving on their own in the community
[15]. (There is more specificity on this problem in
the later discussion of adaptive functioning).
Two main strategies have been tried to get
around the obstacles to developmental services
posed by transforming borderline IDD into BIF,
and thus eliminating from possible assignment to
IDD of many deserving people whose scores fell
above the lowered ceiling: raising the ceiling five
points, on the grounds of ‘standard error’ [16], and
&&
establishing ‘IDD equivalence’, provisions [17 ], in
which for certain conditions, IQ scores can be
waived or interpreted more flexibly. These are all
based on at least the implicit belief that excessive
reliance on IQ SD units to define the IDD category is
somehow wrong.
Raising the IQ ceiling by five points
Early in the history of IDD manuals, mental health
professionals and agencies were encouraged to inter-
pret full-scale IQ scores flexibly, by taking into
account the ‘standard error’ of intelligence tests
[18]. This refers to the fact that no measure is com-
pletely reliable, and one should therefore construct
a confidence interval around an obtained score,
typically specified at the 95% level (this means that
there is a 95% probability that a true score will fall so
many points above or below the obtained score). For
full-scale IQ, the convention is to set the 95% con-
fidence interval as plus or minus five points (even
though for specific tests the number may be differ-
ent, and may even be skewed rather than symmetri-
cal depending on the statistical methods and
population used when developing that test).
This eventually morphed into the advice, both
in the recent AAIDD manuals, as well as in the 2013
DSM-5, that the recommended ceiling, when one
was used (and it was always recommended that rigid
reliance on a ceiling to reject an IDD diagnosis be
avoided) should be 75, rather than 70 [19]. This is
usually justified on standard error grounds, but if
that was really the case it would not always be
interpreted as justifying a raise in the ceiling.
Instead, a more likely reason for raising the IQ
ceiling to 75 (which under the normal curve is at
the 5th percentile) is a policy one, namely a belief
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Borderline intellectual functioning Greenspan
that setting the ceiling at the 2nd percentile was too
low and avoidance of false negatives required it to be
raised. However, using the standard error rationale
enabled the authors of successive manuals to main-
tain the myth that the IDD ceiling had an empirical
(as opposed to rational) justification, by basing it
on a statistical convention. The ‘scientistic’ (i.e.
pseudo-scientific) use of SD as a basis for defining
borderline IDD (and, later, BIF) is addressed in the
Intelligence sub-section and at the end of this sec-
tion. Scientism [20] is a concept that refers to the
questionable use of numbers to create a false impres-
sion of rigor rather than rhetoric, a much-discussed
topic in psychiatric classification [21].
IDD-equivalence provisions
A widely-used technique for getting IDD-like serv-
ices to people with IQ scores in the BIF range is
through equivalency provisions in various human
services statutes, typically under the broader
umbrella of ‘developmental disabilities’ [22]. This
started in the United States when the 1970 Devel-
opmental Disabilities Services and Facilities
Construction Amendments of 1970 was passed,
with mental retardation subsumed under the
broader umbrella of ‘developmental disabilities’.
The developmental disabilities category included
mental retardation, but added an expanded list of
categories, including epilepsy and cerebral palsy,
and then added ‘other neurological conditions
originating before the age of 18’. Clearly, the intent
of this formulation was to provide a loophole for
children and adults deserving of IDD services but
who were prevented from receiving them if their IQs
fell in the BIF range and they did not fall in one of
the few specified disorder categories.
A variant of this Federal legislation was passed in
California as the ‘Lanterman Act’ in the 1970s and
1980s for providing eligibility for developmental
services through the state’s massive regional center
system [23]. As with the Federal legislation, it started
off with a categorical list (of four disorders) and then
switched to a functional ‘fifth category’ intended to
provide developmental services to people who func-
tion as IDD even if their IQ falls in the BIF range.
This fifth category consisted of people with
adaptive functioning profiles similar to those of
people with IDD or who have service needs identical
to persons with IDD, even if their full-scale IQ scores
(typically in the BIF range) were otherwise disqual-
ifying. A range of IDD-equivalency provisions have
been developed in different states for getting around
the problem of children and adults with BIF IQ
scores but who have disorders that clearly should
qualify them as IDD. For example, in the state of
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Neurodevelopmental disorders
Connecticut, all people with Prader–Willi Syndrome
(a chromosomal disorder with IQ scores typically in
the IDD range but sometimes in the BIF range) are
deemed eligible for ID services regardless of IQ (or
for that matter, adaptive functioning) scores [24]. In
other places, for different disorders (for example
Patau or Edwards syndromes in Manitoba), IDD
service eligibility is established regardless of whether
one has a low enough IQ, but only if adaptive
functioning limitations are established [25].
Why should a category be defined by
standard deviation units?
A fundamental problem with the BIF category, and
for that matter the IDD category out of which it was
carved, is the centrality of even numbers of IQ SD
units (minus one, minus two, etc.) to establish both
a disorder’s upper limit and the subcategories within
it. In the 1961 (first modern) AAIDD manual, in
which the Borderline category was included as a
subtype of mental retardation, there was very little
emphasis on IQ SD units; in fact, they were men-
tioned in a single footnote in a single table. In later
manuals, however, they were given much greater
emphasis [26].
There are two reasons why SD units, especially
even numbers of units, are so popular: they give the
impression that there is a scientific basis (a well
known statistical index of variability) for what is
essentially a policy decision (namely where to estab-
lish the boundaries of a condition), and they provide
an easy-to-memorize and simple heuristic for
mental health experts and finders of fact (e.g.
judges, disability agencies) to use when reaching
conclusions about a disorder they may not fully
understand, and a person who they may not have
time to really get to know.
The fact of the matter is that estimated mental
age, which was the original basis for defining IDD
for centuries up until invention of the IQ number,
has many advantages (as long as mental age is
approached holistically, and not derived as a
number from an intelligence test). Among these
advantages are: the fact that mental age taps into
how someone functions broadly, and not just in
solving academic problems, and every adult with
any experience with children, has a basic under-
standing of what children are like and what they
are (and are not) capable of. Even if a heavy reliance
on IQ scores remains part of the definition of IDD
(and given the continued mystique of IQ, it will not
be so easy to get away from that), there is no reason
why the upper boundary of IDD cannot be 79, or 82,
or any number other than what is dictated by the
artifice of a SD unit.
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LEARNING DISABILITY AND BORDERLINE
INTELLECTUAL FUNCTIONING
In the previous section, I discussed the overlap
between BIF and IDD, starting with the fact that
there was earlier a subcategory of borderline IDD,
and ending with the complicating development
that the upper level of IDD has been raised by five
points, thus now causing overlap with a significant
portion of the BIF population. In this section, I
discuss overlap with another category, used primar-
ily within educational settings, namely learning
disability. In discussing this topic, it should be made
clear that I am using the learning disability term as
in appears in the special education literature in the
United States, namely as an indication of a specific
academic impairment – such as reading disability
(dyslexia) or math disability (dyscalculia) [27],
and am not using it as it appears in the disability
literature in the United Kingdom, namely as their
preferred term for IDD (although the term intellec-
tual disability is increasingly being used in the
United Kingdom to bring them more into line
with international practice). Another reason for
removing use of learning disability to indicate
IDD is that IDD is better thought of as thinking
disorder (inflexible use of cognitive schemas) than a
learning disorder (inability to acquire cognitive
schemas) [28].
In theory, learning disability as it is used in the
United States should not overlap with BIF, as diag-
nosis of learning disability (typically termed
‘specific’ learning disability, or SLD) usually requires
normal intelligence, normal adaptive behavior, but
(hypothetically brain-based) difficulties in a single
area of academic achievement such as reading or
math. In practice, however, [29], a large percentage
of students classified with SLD in school have IQs in
the borderline (or even IDD range), have significant
adaptive deficits, and are struggling in all academic
subjects. The likely reason for this misuse of the
learning disability label is that schools today are
very reluctant to assign the IDD label [30], especially
Educable Mental Handicap (EMH, the equivalent of
mild IDD). Thus, to provide services for students
who would formerly have been labeled IDD but who
no longer qualify for needed special services and
thus cannot receive them because their IQ is too
high, these students were assigned to learning dis-
ability classrooms or services, even if they did not
meet any official definition of learning disability.
As example of the bifurcated nature of the learn-
ing disability population, here is a telling anecdote: I
once led a discussion group on the topic of social
competence (my research specialty) for an agency
serving adults with learning disability. Half the
group consisted of successful adults who spent the
Volume 30  Number 2  March 2017

time expressing shame over being unable to read
well, whereas the other half consisted of marginally
functioning adults who spent the time denying that
they had IDD. As a result of this experience, the
support group was split in two, in order to better
address the concerns of these two distinct sub-
groups: one with specific learning disability, the
other with BIF (and social incompetence).
Objections that have been raised to the con-
founding of learning disability and BIF are that: it
makes it difficult to do meaningful research on
learning disability, and it detracts from devising
appropriate services for either the true learning dis-
ability (i.e., SLD) subgroup or the learning disability
subgroup which really has BIF (or even IDD) but is
mislabeled as having learning disability. One
suggested solution to this problem [31], is to carve
out a new educational category at the interface of
learning disability and mild IDD and term it ‘general
learning disability’ (GLD). The main difference
between GLD and SLD is that people with GLD have
IQ scores in the BIF range and academic delay in
most subjects, whereas those with SLD have IQs
above the BIF range and more focused academic
delays. When used as an educational term, GLF –
which might also be termed ‘slow learners’ (a term
widely used at one time but which has fallen out of
favor) – would refer to students who have global
academic impairments, reflecting BIF, but with
generally adequate adaptive functioning. When
referring to slow learners with BIF as well as poor
adaptive functioning, the term could essentially
involve a restoration, in whole or in part, of Border-
line IDD. The main rationale for such a development
is a widespread concern that individuals with BIF
and poor adaptive skills are a very at-risk population
that is not being served adequately either in school
or in the community, as a result of the raising of the
IQ ceiling for IDD designation.
BRAIN SYNDROMES AND BORDERLINE
INTELLECTUAL FUNCTIONING
An interesting development in the disability field is
that—in part, reflecting positive developments such
as early intervention services–the mean IQ of many
brain-based developmental syndromes known to be
causes of IDD today fall in the mild IDD range (when
once they might have fallen in the moderate IDD
range) [32]. As a result, a significant percentage of
‘individuals with brain-based developmental syn-
dromes have IQ scores that fall in the BIF range.
The IDD-Equivalence method, profiled earlier, was
in fact developed to solve the problem facing indi-
viduals with brain-based developmental syndromes
and significant adaptive deficits but whose full-scale
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Borderline intellectual functioning Greenspan
IQ scores cause them to be categorized as BIF rather
than IDD.
An example of a brain-based developmental
disorder where the BIF label is often used to deny
the reality and seriousness of someone’s condition
can be found in fetal alcohol spectrum disorder
(FASD). In Western countries, FASD disorder is argu-
ably the main known cause of IDD (it is malnu-
trition in most developing countries), but it is often
not diagnosed, especially for the majority who lack
&
obvious anomalous facial signs [33 ]. Although
FASD is strongly associated with IDD, only a quarter
to a third are actually diagnosed with IDD, as the
mean IQ for individuals with FASD is around 80,
which is in the BIF range. People with FASD inevi-
tably have psychiatric diagnoses and maladaptive
behaviors (a large percentage become incarcerated)
owing to very poor social judgment related to exec-
utive functioning deficits [34]. IDD equivalency
statutes in some states (particularly Washington,
Minnesota, and Alaska) enable provision of services
or legal protections, but in most places the BIF
diagnosis prevails and serves as an insurmountable
barrier.
RELEVANT FUNCTIONAL DOMAINS
In considering the current and future status of BIF, it
is also important to examine it in relation to
relevant functional domains. Three such domains
shall be briefly discussed: intelligence, executive
functions, and adaptive functioning.
Intelligence and borderline intellectual
functioning
As BIF was (at least until DSM-5) solely defined by
one’s full-scale IQ score, some discussion of intelli-
gence must be part of any treatment of BIF.
Although there are still many who believe that
full-scale IQ deserves to retain its dominant place
at the head of the IDD (and by extension, BIF) table,
the fact is that full-scale IQ is a metric that many
consider to be outmoded and ready if not for the
junk heap, then for a less prominent role [35]. As
mentioned in the next section, many (in line with a
statement in DSM-5) consider executive functioning
to be a more meaningful diagnostic indicator of IDD
&
than IQ. Cross-battery assessment [36 ], using a
profile analysis of data across various IQ tests and
subscales, is also considered a better gauge of some-
one’s level of cognitive functioning and impairment
than is a single summary number from a single test
which contains content mainly tapping academic
potential. (The notion of ‘multiple intelligences’
refers to the fact that there are content areas, such
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Neurodevelopmental disorders
as social intelligence, not tapped at all by an IQ
score.) [37] Furthermore, there is now increased
appreciation of the sources of error affecting IQ
scores, the fact that excess subscale scatter mandates
caution in using full-scale IQ, and recognition of the
need to be more flexible in interpreting any single
&
score [38 ]. It is likely for these several reasons that
DSM-5 diverged from its former definition of BIF
solely in IQ SD range terms, and now leaves the
definition of BIF somewhat vague.
As pointed out by Gould [39], there are two
related myths that underlay the use of IQ scores,
and IQ ranges, to define IDD (and, by extension,
BIF): the myth of reification, and the myth of rank-
ing. Reification refers to the taking of an abstraction
and turning it into concrete reality, treating it as
even the most important form of that reality. Thus,
IQ scores are interpreted as the most important
indicator of functional competence, rather than
merely as only one (and not necessarily the best)
predictor of such competence. Ranking refers to the
idea that people can be meaningfully located on a
continuum from worst to best, on a single domain,
and that one’s rank on that domain can summarize
almost everything one needs to know about that
person. It has been argued that such reductionism is
&
fundamentally unethical [40 ], in that it is a hold-
over from the days of eugenicist fears about inher-
itance of inferiority, and the need for a simplistic
formula for identifying those who present a per-
ceived threat to the purity of the population gene
pool [41].
Executive functions and borderline
intellectual functioning
A reflection of the decreased mystique of full-scale
IQ can be found in a section of the IDD section
of DSM-5 in which it was stated that for many
individuals, performance on neuropsychological
measures, especially ‘executive functions’, is a better
indication of IDD than is full-scale IQ [42]. The term
refers to a grab-bag of measures that tap two broad
ability areas: self-regulatory skills, such as attention
and inhibitory control, and reasoning skills, such as
planning, problem-solving and cognitive flexibility.
These have two advantages over the IQ metric: they
tap skills that are especially important for function-
ing in the world (i.e., that are more directly related
to adaptive functioning), and they are diagnosti-
cally useful in identifying specific brain regions
where impairment may be localized.
A particularly important aspect of executive
functions is that it sheds light, at least indirectly,
on consequential thinking, that is the understand-
ing and prediction of problems that might result
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from certain actions or inactions [43]. Because of
the importance of executive functions as an
indicator of IDD and of brain impairment, it stands
to reason that it could be used to indicate when
someone with BIF has a low IQ for neuro-develop-
mental, rather than sociocultural, reasons. If an
individual with BIF also has significant deficits in
executive functions (regardless of their race or
ethnicity), then it would make sense to move that
person over into the IDD category, whereas if exec-
utive functioning is normal, then a BIF diagnosis
might be more appropriate.
Adaptive functioning and borderline
intellectual functioning
The term adaptive functioning refers to how some-
one functions in the world, as opposed to how he or
she functions on an IQ test. Adaptive functioning is
mildly correlated with IQ (just as almost anything is
mildly correlated with IQ) [44], in part because IQ
is a gross indicator of brain health [45]. However, at
extremely low levels of intelligence, adaptive func-
tioning is likely to be significantly impaired, while
at milder levels of cognitive impairment, adaptive
functioning deficiency may be quite subtle and
difficult to discern [46]. Since 1961, the definition
of IDD required deficits in both IQ and adaptive
functioning, to avoid the false positive problem
(people wrongly assigned the intellectual develop-
mental label), especially when below average IQ
reflected culture as opposed to impaired brain func-
tioning or development.
Adaptive functioning is an inadequately defined
construct [47], but there is consensus that it refers to
skills and competencies, and does not refer to
positive mental health, desirable personality traits,
or the absence of maladaptive behaviors. Three
domains of adaptive functioning have been ident-
ified: conceptual adaptive skill (functional academ-
ics), practical adaptive skill (activities of daily
living), and social adaptive kills (interpersonal
understanding and insight). In line with the current
understanding that people with IDD can have areas
of near-normal functioning, the official require-
ment is for significant adaptive functioning deficits
to be found in only one of the three above-
mentioned domains.
Adaptive functioning is generally measured
clinically by third-person ratings on standardized
rating instruments but direct measures are begin-
ning to be published [48]. Ultimately, descriptive
and qualitative information may be the most
important, but agencies (such as courts) are enam-
ored of numbers. A controversy in the adaptive
functioning literature, with particular relevance to
Volume 30  Number 2  March 2017

BIF, concerns a sentence in DSM-5 in which it is
stated that there should be some relatedness
between criteria A and B. What this means is that
for the bulk of people with high-functioning IDD,
including many people with BIF, the essence of
adaptive functioning deficiency is found not in
automatized low-level skills such as self-care, but
in cognitively-mediated skills or deficiencies such
as social judgment, risk recognition, gullibility,
problem-solving and anticipation of consequences
[49]. These are all skills that are mediated more by
executive function than by IQ.
If, as is recommended in the final section of
this study, BIF is eventually folded into an expanded
IDD category, then adaptive functioning will
become an important part of the diagnostic process
for BIF as it is for IDD. Currently, AF assessment is
not a requirement for receiving the BIF label (which
in practice continues to be based entirely on IQ
score), but it should be. That is because for many
(but not all) people with BIF, social judgment
(especially anticipation of consequences) is very
impaired, and contributes to great difficulty in
maintaining employment and independent living.
Here is but one example of how someone with
BIF can have very impaired AF: a young man, ‘Mike,’
with an IQ in the middle of the BIF range, was
working as a night clerk at a franchise gas station
/ convenience store, when he got a call at 2 a.m.
from someone claiming to be with the national
corporate office for the chain. This person asked
the young man for the serial numbers on gift cards
that were on sale at the store. Mike was alone in the
store, and did as asked without thinking to call his
boss or tell the caller to do so. The next day Mike was
terminated when the boss informed him that he had
been defrauded of $3000. When Mike (who like
most people with IDD, covered up his limitations
through habitual compliance) was asked why he did
as asked he replied ‘but he was from the central
office’. It did not occur to Mike that central office
personnel do not typically work at 2 a.m., and he
was oblivious to the possible risk to which he was
exposing the store (and himself) by his unquestion-
ing obedience to someone he did not know.
CONCLUSION
In this concluding section, issues discussed earlier
will inform a consideration of the future of
the construct. Two applied topics—poverty and
criminal justice—are also discussed, both because
BIF label is commonly applied to poor or incarcer-
ated individuals, but also because consideration of
the former led to the creation of the BIF label in the
first place, and consideration of the latter plays
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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Borderline intellectual functioning Greenspan
an important role in the call to convert the BIF
v-code into something more like a disorder than a
description.
Poverty and borderline intellectual
functioning
No discussion of BIF can avoid some discussion of
race, culture, and socioeconomic status. Because the
mean IQ scores of poor minority individuals are
around one SD lower than for the general popu-
lation, people who are poor and minority were more
likely to be wrongly labeled IDD [50]. It was to avoid
that form of what was rightly seen as a form of
discrimination, that Borderline IDD was trans-
formed into BIF. As a consequence, people who
are poor and minority are today more likely to be
labeled BIF. Thus, BIF is seen somewhat as a poverty
disorder. That is one of the several reasons why if
there is a way to separate out and identify the subset
of BIF people who truly do have IDD, that eliminat-
ing BIF is probably a good idea.
A general problem in evaluating people who are
poor and minority for the possibility of having IDD
is what has been termed ‘cultural overshadowing’
[51]. That term refers to the tendency to use corre-
lated aspects of someone’s ethnicity (for example,
presumed inadequate socialization) to explain all
aspects of his or functioning, in the process ignoring
personal risk factors (such as a diagnosed brain
disorder) and other countervailing facts (such as
the existence of accomplished siblings). This con-
tributes to the overuse of the BIF code for minority
individuals, on the assumption that their impaired
academic functioning solely reflects culture, even
when organic indicators would suggest otherwise.
Criminality and borderline intellectual
functioning
It is well established that incarcerated juveniles and
adults are likely to have low IQs (both on jail or
prison brief screening tests and from comprehensive
measures administered when they were in school)
and to have received cognitively-based diagnoses
such as learning disabilities, IDD and BIF [52].
Furthermore, they are much more likely to have a
positive history for brain-based disorders such as
traumatic brain injury, and FASD. In addition to
this correlational association, there likely is a partial
causative connection, in that people with lower IQ
(especially with brain damage) are more impulsive
and have poor social judgment (as reflected in
gullibility toward antisocial peers) and thus are
more likely to engage in criminal acts that cause
them to end up incarcerated [53].
www.co-psychiatry.com 119
Neurodevelopmental disorders
But the criminality topic has also made an
important contribution to the definition of IDD
and BIF in a more direct way, and that is because
it has caused increased attention to be paid to the
nature and limitations of current definitions and
diagnostic practices. The context for this increased
scrutiny is the proliferation of death penalty legal
proceedings, following the Supreme Court ruling in
Atkins v Virginia which outlawed imposition of the
death penalty for people who have IDD. Because of
the much greater seriousness of ruling IDD in or out
in a capital case (when compared to the granting or
withholding of supportive services), a vigorous
debate about the various aspects of an IDD diagnosis
has broken out with regard to all three of the
&
diagnostic criteria [54 ]. One issue that becomes
apparent to any forensic expert who testifies in such
cases, and reads the various reports that have been
written on a capital defendant, concerns how fre-
quently a diagnosis of BIF has been used, often
inappropriately, to deny an IDD diagnosis to a
deserving individual. An aspect of this involves
disputing the (well established) reality of the ‘Flynn
effect’ (correcting of full-scale IQ scores downwards,
to reflect the obsolescence of older test norms),
thus forcing someone inappropriately into the BIF
category [55].
A major advance on the Atkins legal front, and
one with implications for making further inroads
into the BIF category, was made in an award-
winning legal analysis by Clemente [56]. The
analysis was inspired by what was considered a
misunderstanding of the history of IDD by the US
Supreme Court when it decided its 2002 Atkins v
Virginia decision which spared the death penalty for
people with IDD [57]. A debate preceding that ruling
concerned the position of British Common Law
about the culpability of people with IDD before
the US Constitution was adopted in 1790. The
reason why that was important was because strict
constructionists, led by Justice Scalia, argued that
rights not explicitly specified in the Constitution
could be grandfathered in only if they were pro-
tected in Common Law before the Constitution
was enacted.
Under Common Law, ‘idiots’ were exempt from
execution, and the opponents of the ruling—using
the eugenicist taxonomy instituted in the United
States and Britain in the early 20th century –
assumed the term covered only the most severely
impaired offenders (that is, who had IQs in the 40s
or below) and thus opposed the extension of that
exemption to people with milder forms of IDD.
Accepting the truth of that historical assumption,
the majority in Atkins argued for extending the
exemption to mildly impaired defendants on the
120 www.co-psychiatry.com
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
basis of ‘evolving standards of decency’ as reflected
in the growing number of states and countries that
abolished the death penalty for people with IDD.
Because the decency argument is not universally
accepted, the ruling in Atkins passed only with a
five to four vote. Examining a 1737 treatise by Sir
Matthew Hale [58], who was considered the leading
authority on criminal jurisprudence in the early
18th century, Clemente found, however, a state-
ment that idiots were people who as adults never
progressed beyond the level of a 14-year-old. Thus,
idiocy in that time period differed from later eugen-
icist formulations, and took in the whole spectrum
of IDD individuals, including people who today
would be labeled as BIF. Using a mental age to IQ
equivalency formula (with 13.5 set as the ceiling
age), Clemente argued that the US Supreme Court
could have extended Atkins protection under the
Original Intent formulation to cover all people with
IDD up to an IQ score in the low 80s (i.e., people
with both mild IDD and BIF), without having to
invoke the evolving decency argument.
Future of borderline intellectual functioning
As BIF started out as a subtype of IDD, and as the
diagnosis of BIF is typically an alternative to a diag-
nosis of IDD, any discussion of the future of BIF must
be accompanied by a broader discussion of the
future of IDD. It has already been noted that a chunk
of BIF has already been carved off, as a result of the
raising of the IQ ceiling for IDD (in DSM-5 and other
manuals, and in court decisions) from 70 to 75. So,
assuming that IQ range continues to be a core
method when the BIF label is assigned by clinicians,
a question to be asked is ‘what should be done with
the other 10 points, between 75 and 85?’
The main reason why an even higher IQ ceiling
(85, which was the upper boundary of borderline
mental retardation’) was abandoned in 1973 – thus
transforming BMR to BIF – was that the newly
established second diagnostic criterion, adaptive
functioning (for which standardized instruments
had not yet been developed) was routinely ignored
[59]. That is no longer the case, as there are now
several adequately normed instruments, and this
second criterion is now almost universally used
when a diagnosis of IDD is being considered. For
that reason, the original rationale for casting a wide
net for criterion A (intellectual functioning) –
namely that Criterion B (adaptive functioning)
would reduce the prevalence substantially – now
has validity, whereas before it did not.
Another reason to consider raising the IDD
ceiling even further (above 75) is that so many
neurodevelopmental syndromes (such as FASD)
Volume 30  Number 2  March 2017

have mean IQ scores between 76 and 85. Raising
the ceiling to 85 (or even to 80) would, therefore,
create a more adequate framework for providing
appropriate services and protections to people with
such disorders, without the need for IDD-equival-
ence statutes (which, currently, affect only a few
disorders, are not found in all jurisdictions, and are
not uniformly worded or applied). Obviously, such a
designation should only be made if other cognitive
indices (especially measures of executive functions)
are supportive, and only if the individual shows
significant signs of adaptive impairment.
In sum, a consideration of the issues addressed
in this study leads one inevitably to the following
conclusions: that a higher ceiling for Criterion A
(intellectual deficits) for defining IDD should be
instituted, and that the v-code BIF should be
dropped from future inclusion in diagnostic
manuals. If BIF is kept as a v-code, there should
be more emphasis on a statement in DSM-5 to the
effect that some people with BIF can and should be
diagnosed with IDD. Furthermore, there should be a
rejection of the outmoded idea that a psychiatric
diagnosis can be based on a statistical convention
(standard deviation), using a summary number
derived from a single test. Intelligence remains an
important construct for understanding human
competence, but a more nuanced understanding
of people with marginal intelligence, and their
problems of functioning in the world, is needed
&&
[60,61 ,62].
Acknowledgements
Harvey N. Switzky, PhD, for stimulating my thinking
about this topic.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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Volume 30  Number 2  March 2017