Borderline Intellectual Functioning: A Systematic Literature Review

INTELLECTUAL AND DEVELOPMENTAL DISABILITIES ’AAIDD
2014, Vol. 52, No. 6, 419–443 DOI: 10.1352/1934-9556-52.6.419
Borderline Intellectual Functioning: A Systematic

Literature Review
Minna Peltopuro, Timo Ahonen, Jukka Kaartinen, Heikki Seppälä, and Vesa Närhi
Abstract
The literature related to people with borderline intellectual functioning (BIF) was systematically
reviewed in order to summarize the present knowledge. Database searches yielded 1,726 citations,
and 49 studies were included in the review. People with BIF face a variety of hardships in life,
including neurocognitive, social, and mental health problems. When adults with BIF were
compared with the general population, they held lower-skilled jobs and earned less money.
Although some risk factors (e.g., low birth weight) and preventive factors (e.g., education) were
reported, they were not specific to BIF. The review finds that, despite the obvious everyday
problems, BIF is almost invisible in the field of research. More research, societal discussion, and
flexible support systems are needed.
Key Words: borderline intellectual functioning; mild cognitive limitations; slow learners; systematic
literature review
People with borderline intellectual functioning retardation, slow learner, mild cognitive impairment,
(BIF) have an IQ test score that is one to two and general learning disability.
standard deviations below average, in the range of Historically, there has been interest in BIF in
70 to 85. If normal distribution of intelligence is the intellectual disability (ID) community in the
considered, 13.6% of the population fits into that late 1960s and again in the late 1990s. In the 1960s,
category. Not all of the people who score in this the American Association on Intellectual and
IQ range have problems with adaptive behavior Developmental Disabilities (AAIDD; formerly
(conceptual, social, and practical skills), nor do called the American Association on Mental
they all need support, but this figure can be used Retardation) defined those with an IQ test score
as a guide. Despite the high percentage of people of 70 to 85 as eligible for classification as mentally
in this category, BIF is a rarely studied topic. retarded (Heber, 1959, 1961). The report by the
When it is included in studies, the focus of the President’s Committee on Mental Retardation
research is often on people with mild intellectual (PCMR), ‘‘The Six-Hour Retarded Child,’’ identi-
disability (MID) or a specific learning disability fied the group of children who were labeled as
(SLD), and the BIF group is either combined with mentally retarded during school hours based solely
these or treated as a control group. There seem to on an IQ test score without regard to their adaptive
be two traditions examining BIF: medical and behavior (President’s Committee on Mental Retar-
pedagogical. Generally speaking, the medical dation, 1969). Outside the academic setting,
tradition concentrates on BIF as a consequence however, these children seemed to manage reason-
of some medical condition, and the pedagogical ably well. The report was also concerned with
tradition concentrates on the difficulties of overrepresentation of ethnic groups and poverty
teaching children with BIF. A research tradition among those children labeled as mentally retarded.
focusing on BIF for its own sake, however, is In the early 1970s, the classification system around
lacking. There is also no unanimous term for the mental retardation was modified, and BIF was
phenomenon of BIF, and it has had numerous removed from the diagnostic category (Grossman,
names in the past. The names used in the 1973). Three decades later, the PCMR revisited
literature include, for example, borderline mental ‘‘The Six-Hour Retarded Child’’ in a report and
M. Peltopuro et al. 419

2014, Vol. 52, No. 6, 419–443 DOI: 10.1352/1934-9556-52.6.419
book entitled The Forgotten Generation (President’s manuals emphasize the role of adaptive behavior. In
Committee on Mental Retardation, 1999; Tym- the International Classification of Diseases (ICD-10;
chuk, Lakin, & Lucasson, 2001). The general World Health Organization [WHO], 1992), mental
proposition of the report was that adults with mild retardation is described as a condition of arrested or
cognitive limitations face challenges in every incomplete development of the mind. It is charac-
aspect of life—finances, employment, housing, terized by impairment of the skills that contribute
well-being, and family—and that they become to intelligence (i.e., cognitive, language, motor,
more vulnerable as the demands of society grow and social abilities). The role of IQ is emphasized
increasingly complex. This proposition was sup- when the manual describes the degrees of mental
ported by Fujiura (2003) when he studied a group of retardation that are estimated by standardized
Americans with mild intellectual impairments and intelligence tests and that can be supplemented
found a sizable cohort of Americans who shared by assessing social adaption.
many support needs and social and economic For the people with BIF, all the manuals imply
vulnerabilities with those labeled as ‘‘mentally the same difficulty: However severe a person’s
retarded.’’ This cohort was distinguishable from problems with adaptive behavior may be, people
the general population of the United States as well with BIF are not eligible to receive a diagnosis of ID
as from those with SLDs. and they cannot gain access to ID-related support
Since 1973, BIF has not been included in any and services because their IQ is ‘‘too high.’’ This is
diagnostic category. The 11th edition of the true if IQ is used as an eligibility criterion instead of
AAIDD manual (Schalock et al., 2010) defines needs-based access to support and services. People
intellectual disability as being characterized by with BIF can also be left without appropriate support
significant limitations (approximately 2 standard in school because they are not necessarily eligible for
deviations below the mean) in both intellectual the special education services meant for students
functioning and adaptive behavior. Even though with SLDs. In the DSM-5, SLD is described as a
BIF does not meet the diagnostic criteria of ID, the ‘‘specific learning disorder’’ and in ICD-10 it is
AAIDD manual recognizes it by describing indi- defined as ‘‘specific developmental disorders of
viduals who fall slightly above the upper ceiling for scholastic skills.’’ Both definitions include the
a diagnosis of ID and often face challenges in assumption that learning difficulties are not attrib-
society that are similar to those faced by persons utable to intellectual disabilities and that there is a
with ID who have lower IQ scores. The manual discrepancy between performance in academic skills
calls for nonstigmatizing, accessible, and individu- and the general level of intelligence.
alized support for these people. In the Diagnostic and The field now acknowledges, in research as
Statistical Manual of Mental Disorders (5th ed.; DSM- well as in practice, the multiple social and
5; American Psychiatric Association, 2013), BIF is functional problems as well as the lack of targeted
recognized in a section labeled ‘‘other conditions support related to BIF. But despite this acknowl-
that may be the focus of clinical attention.’’ The edgement and the earlier interest in the topic, the
manual advises that differentiating BIF and mild ID research remains scant. There is still no unanimous
requires careful assessment of intellectual and name for the phenomenon and no norms to guide
adaptive functions and their discrepancies. The how to treat people with BIF. The purpose of the
manual defines intellectual disability as a disorder present study is, in addition to increasing knowl-
that includes both intellectual deficits (approxi- edge about the problems and risk factors related to
mately 2 standard deviations below mean; IQ test BIF, to examine the prevalent situation in light of
score of 65–75) and adaptive functioning deficits. current literature and to bring the topic up for
DSM-5 emphasizes the role of adaptive function- societal and research discussion. First, we were
ing. It advises that the levels of severity should be interested in the general information on studies
defined based on adaptive functioning and that concerning BIF: publication and population details,
clinical judgment should be used when interpreting the terms used, and the quality of the studies.
the results of IQ tests. DSM-5 also points out that Second, we wanted to know what difficulties people
IQ test scores are approximations of conceptual with BIF face across their life courses in comparison
functioning and that, for example, a person with an to those the general population faces. Third, we
IQ test score above 70 may have severe problems in attempted to determine whether there were any risk
adaptive functioning. The DSM-5 and the AAIDD or preventive factors visible in the studies.
420 BIF Review

2014, Vol. 52, No. 6, 419–443 DOI: 10.1352/1934-9556-52.6.419
Methods Intellectual Disabilities, and Journal of Intellectual

In our study, we systematically collated empirical Disability Research) from the beginning of 2000 to
group evidence that fit prespecified eligibility March 2012. These journals were selected on the
criteria in order to answer research questions. We basis that they were the ones most commonly found
used explicit, systematic methods that were selected in the reference lists of the studies that had already
with a view to minimizing bias. been included.
Eligibility Criteria Study Selection Process

We originally planned to include studies if the Citations identified through database searches were
participants in them had an IQ test score measuring transferred to the reference management program
70 to 85. However, as only a few studies used this RefWorks (www.refworks.com) and duplicate
exact criterion (Table 1), we also included studies citations were removed. The titles and abstracts
where most of the subjects in a BIF group met the were examined and a study was excluded if the
criterion. No age limits for the participants were inclusion criteria were not met. The excluded
set. Group studies reporting results relevant to the records were coded into one of four categories: (a)
study questions were included. Outcomes were ‘‘no IQ’’: intelligence quotient was not determined
considered relevant if they dealt with neuropsy- in the study; (b) ‘‘wrong IQ’’: intelligence quotient of
chological, social, mental health, independence, most of the participants did not fall within the range
risk, or preventive issues. of 70 to 85; (c) ‘‘not a group study’’: only group
studies were included in order to collate extensive
information; and (d) ‘‘irrelevant results’’: the results
Search Methods for Identification
of the study were irrelevant to our study questions. If
of Studies the criteria were fulfilled, or fulfillment was
In March 2012, we carried out our electronic
uncertain, the studies were included for full-text
database searches. The following databases were
evaluation, and they were assessed for eligibility
searched: ERIC (Educational Resources Information
using the four categories previously described. If
Center, 1960 to March 2012), ISI (Web of Science,
the reason for exclusion was ‘‘irrelevant results,’’
1945 to March 2012), MEDLINE (1950 to March
the study was marked on an extraction sheet (see
2012), and PsycINFO (1887 to March 2012). All
‘‘Methods for Handling Data’’). The studies that
searches were restricted to the English language.
fulfilled the inclusion criteria were included in the
The search strategy used to search ISI was ‘‘Topic,’’
final sample for systematic review. At this point,
which searches the title, abstract, and key words of
the studies identified through additional searches
the records. This search was modified as necessary
were included in the sample. The study selection
to search other databases (modifications available
process was carried out by the first author (MP, a
upon request from the first author). The search terms
doctoral student). Reliability was confirmed by
(combined with ‘‘or’’) were as follows: borderline
two reliability checks: random samples of 88
developmental disability, borderline intellectual
functioning, borderline intellectual disability, bor- (7.3%) citations identified through database
derline IQ, borderline learning disability, borderline searches, and 10 full-text articles (5.8%) were
mental retardation, minor intellectual disability, coded by another author (VN, PhD). In both
general learning disability, general learning disorder, checks, the initial agreement between coders was
gray-area children, marginal learners, slow learners, 90% and a final consensus was reached by
garden variety slow learners, and nonspecific learn- discussing the differences.
ing disabilities.
In addition to these searches, we carried out Methods for Handling Data
two other searches in the same period. We noted An extraction sheet was used for the studies that
the references of the studies included for review were excluded as irrelevant. The sheet covered
from the database searches and then conducted a author, publication year, population characteris-
manual search for the titles and abstracts in four tics, aim, results and conclusions, and reasons
journals (American Journal on Intellectual and for exclusion.
Developmental Disabilities, Intellectual and Develop- An inclusion sheet was used for the included
mental Disabilities, Journal of Applied Research in studies to collect descriptive information. The

2014, Vol. 52, No. 6, 419–443 DOI: 10.1352/1934-9556-52.6.419
Table 1
Publication and Population Details of the 49 Included Studies
Study (Lead Author) Country N BIF n Age Male % BIF IQ BIF sample recruited from
Alloway, 2010 UK 78 39 7–11 69.2 70–85 Mainstream school
Atkinson, 1984 UK 45 45 45–51 100 49–82 Special school
Birch, 2003 US 186 79 6–12 47.8 71–89 Mainstream school
Bonifacci, 2008 UK + IT 111 32 6–15 - 70–85 Clinic
Chaudhari, 1999 IN 272 - 6 - 70–85 Hospital birth cohort
Chaudhari, 2004 IN 270 - 12 - 70–85 Hospital birth cohort
Chen, 2006 US 1681 178 27–33 45.8 70–80 Hospital birth cohort
b
Claypool, 2008 CA 196 59 10.9 55 70–79 Clinic
Crocker, 2007 CA 281 - 31.3 b 100 71–85 Criminal justice
Cuvo, 1992 US 11 - 18–24 - 69–84 Clinic
Dekker, 2003 NL 474 367 6–18 61.8 60–80 Special school
Douma, 2006 NL 1328 281 11–18 49 .70 Special school
Douma, 2007 NL 1556 - 11–24 48.1 60–80 Special school
Embregts, 2009 NL 136 54 10–14 100 78.5 b Special school
Emerson, 2010 AU 4337 598 6–7 - 70–85 General population
Farhadifar, 2011 IR 200 100 6 - 70–84 Mainstream school
Fenning, 2007 US 217 29 5 58.1 71–84 Clinic
Fernell, 2010 SE 117 38 16 75.2 70–84 General population
Guralnick, 1987 US 64 16 2–5 100 59–86 Clinic
Hartman, 2010 NL 194 61 7–12 58.8 70–79 Special school
Hassiotis, 2008 UK 8450 1040 16–74 - 70–84 General population
Hassiotis, 2011 UK 6872 1053 16 , 48.2 70–85 General population
Henry, 2001 UK 78 10 11–12 66.7 70–79 Special school
Hollander, 1985 US 200 - 12–18 100 70–85 Criminal justice
Karande, 2008 IN 55 - 8–17 63.6 71–84 Clinic
Kinge, 1979 a NO 262 59 30 52.3 69–85 Town birth cohort
Kortteinen, 2009 FI 155 62 8th grade 33–77 71–84 Mainstream school
MacMillan, 1998 US 150 - 7–12 59.3 71–85 Mainstream school
Maehler, 2009 DE 81 27 2 to 4 grade - 55–85 Clinic
Mähler, 2005 DE 60 20 7–10 - 75 b Special school
Marlowe, 1983 US 135 64 4–16 - 55–84 Mainstream school
McAlpine, 1991 NZ + US 511 25 5–66 48–78 1 SD below Residential facility
Napora-Nulton, 2003 US 117 28 9–12 100 70–79 Clinic
O’Brien, 1996 US 70 14 4 - 70–79 Clinic
Ramey, 1992 US 985 - 3 50 71–85 Clinic
Roberts, 1991 AU 190 95 8–13 72.6 47–85 Clinic
Schuchardt, 2010 DE 107 38 7–15 57 70–84 Special school
Schuchardt, 2011 DE 63 19 7–15 - 70–84 Special school
Schuster, 1982 US 102 - 11–15 94 70–79 Criminal justice
Seltzer, 2005 US 402 201 54 b 49.3 61–85 High school graduates
Seltzer, 2009 US 730 - 53.45 b 49.2 61–85 High school graduates
b
Swanson, 1994 US 143 17 10.78 54.5 70–90 Mainstream school
Thompson, 1990 US 79 14 6–15 70 70–84 Clinic
(Table 1 continued)
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2014, Vol. 52, No. 6, 419–443 DOI: 10.1352/1934-9556-52.6.419
Table 1
Continued
Study (Lead Author) Country N BIF n Age Male % BIF IQ BIF sample recruited from
Vaillant, 2000 US 111 39 14–65 100 ,87 At risk youths
Van der Meer, 2004 NL 58 19 10–12 81 73 b Special school
van Nieuwenhuijzen,
2011 NL 142 38 8–12 71.1 80.5 b Special school
Vuijk, 2010 NL 170 115 7–12 64.1 71–84 Special school
Westendorp, 2011 NL 411 88 7–12 72.5 71–79 Special school
Zetlin, 1990 US 20 20 18.9 b 40 70–84 Special school
Note. Dash represents information that is not reported.
a
Sample details from Svendsen, 1983. b Mean.
following information was gathered: author, year, locations were the Netherlands (18%), United
country, journal, number of participants (study/ Kingdom (12%), Germany (8%), India (6%), Aus-
control groups), gender, age, term used, data tralia (4%), Canada (4%), and one study each from
collection year, how data was collected, IQ score Italy, Norway, Finland, New Zealand, Sweden, and
and how it was measured, aims, hypotheses, main Iran. The sample sizes varied between 11 and 8,450
outcomes, and main conclusions. subjects (mean 667). The total of all subjects was
The methodological quality of the included 32,663. Of the studies, 48% focused on children, 23%
studies was evaluated using the criteria created by on children and adolescents, 10% on adolescents, 12%
Dalemans, De Witte, Wade, and Van Den Heuvel on adults, and the rest spanned multiple age groups. In
(2008). They based their list on different criteria lists 26 studies, the majority of subjects was men; in only
for nonrandomized studies (Downs & Black, 1998; two studies was the majority composed of women.
Prins, Blanker, Bohnen, Thomas, & Bosch, 2002). Terms used. Of the original 16 terms included
The criteria list has later been used also by in the database searches, seven were used in the
Verdonschot, de Witte, Reichrath, Buntinx, and included studies: borderline intellectual disability (in
Curfs (2009). The list consists of 15 items: six items seven studies), borderline intellectual functioning
describe aspects of informativity, four items describe (15), borderline intelligence (eight), borderline IQ
external validity, and five items describe internal (six), borderline learning disability (one), borderline
validity. Two authors (MP and VN) assessed the mental retardation (four), and slow learners (five).
quality of all the studies independently, reaching Methodological quality of the studies. The
initial agreement of 91% (Cohen’s kappa 0.78). Final methodological quality rating of the studies varied
consensus was reached by discussing the differences. between five and 15 (maximum possible 15), with
the mean being 10.9 (see Table 2). In general,
Results informativity and internal validity were better than
Figure 1 shows the study selection process. The external validity.
database searches produced 1,726 citations. On the Only 8.2% of the studies were conducted with
basis of the title and abstract evaluations, full texts general population samples. Subjects with BIF were
of 203 studies were obtained, of which 45 were often recruited from clinics or hospitals (30.6%),
included in the final sample. Four studies were and from special schools or special education classes
found by the additional searches, bringing the final (30.6%; Table 1).
number of studies to 49.
Neurocognitive Functioning
General Information on Studies Academic and cognitive skills. Eighteen stud-
Publication and population details. Table 1 ies concentrated on the academic or cognitive skills
shows publication and population details of all 49 of people with BIF. The studies, recruitment
studies. Of these, 33 were published after 2000, 10 in processes of the subjects, tests used, and outcomes
the 1990s, 5 in the 1980s, and 1 in the 1970s. Thirty- are described in detail in Table 3. Limitations for
nine percent took place in the United States. Other generalization and comparison of results are set by

2014, Vol. 52, No. 6, 419–443 DOI: 10.1352/1934-9556-52.6.419
Figure 1. Flowchart of the study selection process.
the different subject recruitment processes among Bonifacci & Snowling, 2008; Henry, 2001; Kort-
the studies. The place of recruitment varied between teinen, Närhi, & Ahonen, 2009; Maehler &
mainstream schools (six studies), special schools Schuchardt, 2009; Schuchardt, Gebhardt, & Maeh-
(nine), and clinics (three). In addition to below- ler, 2010; Swanson, 1994). Overall, children with
average IQ, criteria for recruiting the subjects also BIF were outperformed by peers of the same age
included reading difficulties (in 3 studies), mathe- with average intelligence. Two exceptions were
matical difficulties (1), and poor school performance reported for visual memory by Henry (2001) and
(3). It is thus possible that participants with Kortteinen et al. (2009). They found no differences
difficulties in academic achievement were overrep- between the BIF group and the control groups.
resented in the BIF samples. The methodological Henry also studied more complex memory func-
quality scores of the studies (Table 2) varied from 5 tions, in which the performance was at the same
to 14 (mean 9.7). The number of subjects varied level in both groups, although Henry believed a
between 45 and 411 (mean 134). ceiling effect for the average control group was
An assessment of memory skills was included possible. In general, a deficit in memory functions
in eight studies (Alloway, 2010; Birch, 2003; of people with BIF seems clear. In 51 tasks,
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2014, Vol. 52, No. 6, 419–443 DOI: 10.1352/1934-9556-52.6.419
performance was poorer than that of average Kortteinen et al., regarding their participants with
intelligence peers, and in only six tasks was BIF and reading disabilities (RD; 47% of their
performance at the same level for both groups. participants with BIF also had RD). However, the
Schuchardt et al. (2010) and Schuchardt, reading and spelling skills of the participants with
Maehler, and Hasselhorn (2011) studied whether BIF and no RD were at the level of average
the deficits in working memory functions reflect a controls. Bonifacci and Snowling (2008) as well as
developmental lag or a qualitative deviation from Claypool et al. (2008) found reading skills to be
normal development by matching the mental ages better in the average control group. Although
of children with BIF with those of average Atkinson (1984) did not compare the adults in his
intelligence. In the first study (2010), they reported study directly with the average control group, the
that children with BIF show structural abnormal- results indicate poor reading skills among the
ities in their phonological store, and developmental adults, because 17% were defined as semiliterate
lags in their visuospatial and central executive and 12% as nonreaders. Regarding the other skills
subsystems. After the second study (2011), howev- related to reading and spelling that were studied,
er, they concluded that, because the performance of performance in most of the others tasks was poor
children with BIF corresponded with that of a (auditory processing, phonological and syntactic
control group matched for mental age, the findings skills, and reading comprehension; Birch, 2003;
indicated a developmental lag. Hence, these Kortteinen et al., 2009). For participants with BIF
children’s working memory functions seemed to and no RD, rapid naming performance was at the
develop in line with their general intellectual level of those in the average control group, but for
abilities. those with BIF and RD, task outcomes were poorer
Alloway (2010) and Hartman, Houwen, Scher- (Birch, 2003; Kortteinen et al. 2009).
der, and Visscher (2010) studied the executive A study on acquiring abstract theories (Mähler,
functions of children with BIF by comparing them 2005) reported that students with BIF used theories
with a control group of children of the same age. that were more immature than the ones used by
Hartman et al. (2010) studied planning skills, and their peers of average intelligence. They preferred
Alloway examined shifting attention, cognitive intentional mechanism as a relevant causal expla-
inhibition, problem solving, planning, and response nation (e.g., ‘‘If I wish my child to have blue eyes,
inhibition. Poorer results were detected systemati- she will have them.’’) over more sophisticated
cally in all presented tasks. A few other studies also mechanisms. Children with BIF were also found to
examined skills related to executive functions. use less advanced learning strategies than other
Napora-Nulton (2003) studied processing speed in children used. For example, they preferred an
familiar and novel situations, and reported all ‘‘isolation strategy’’ over a ‘‘global strategy’’; that
reaction times as being slower in the BIF group is, they focused on a single element of a task rather
than in the average children. In addition, Bonifacci than on its global element (Swanson, 1994).
and Snowling (2008) studied processing speed. Four Swanson also found that students with BIF benefit
reaction-time tests showed poorer performance (in less from hints or clues than students in control
speed and in accuracy) for children with BIF than groups do.
for the children in the control group, as did the test In their follow-up study, Fernell and Ek (2010)
of sustained attention. However, van der Meer and reported that pupils with BIF, assessed in Grade 4,
van der Meere (2004) reported impulse control received grades that were significantly lower when
skills of children with BIF as being similar to those finishing compulsory school than those received by
of children in the control group with average their peers with average intelligence.
intelligence. Motor skills. Three studies (Hartman et al.,
The arithmetic skills of children with BIF were 2010; Vuijk, Hartman, Scherder, & Visscher, 2010;
constantly observed to be poorer than those of the Westendorp, Houwen, Hartman, & Visscher, 2011)
children in the average control group (Claypool, reported on the motor skills of children with BIF.
Marusiak, & Janzen, 2008; Kortteinen et al. 2009; Vuijk et al. (2010) found that 40% of children with
MacMillan, Gresham, Bocian, & Lambros, 1998). BIF showed no problems with motor skills, 17%
The results for reading, spelling, and related skills showed borderline problems, and 43% showed
were not as clear. MacMillan et al. (1998) found definite motor problems when their performance
reading and spelling skills to be poor, as did was compared with the norms of the Movement

2014, Vol. 52, No. 6, 419–443 DOI: 10.1352/1934-9556-52.6.419
Table 2
Quality Assessment of the Included Studies
Informativity External validity Internal validity

Study (Lead Author) a b c d e f Subtotal g h i j Subtotal k l m n o Subtotal Total
Alloway, 2010 + 2 + + 2 + 4 2 + + 2 2 + + + + 2 4 10
Atkinson, 1984 + + 2 + + + 5 2 + 2 2 1 2 2 2 2 2 0 6
Birch, 2003 + + + + 2 + 5 + + + + 4 + + + + 2 4 13
Bonifacci, 2008 + + + + 2 + 5 2 2 + 2 1 + + + + 2 4 10
Chaudhari, 1999 + + + + + 2 5 + + + + 4 + 2 + 2 2 2 11
Chaudhari, 2004 + + + + + 2 5 + + + + 4 + 2 + 2 2 2 11
Chen, 2006 + + + + 2 + 5 + + + + 4 2 + + 2 + 3 12
Claypool, 2008 + + + 2 2 + 4 2 2 2 + 1 2 + + + 2 3 8
Crocker, 2007 + + + + 2 + 5 2 + + + 3 + + + 2 2 3 11
Cuvo, 1992 + + + 2 2 + 4 2 2 + 2 1 + 2 + + 2 3 8
Dekker, 2003 + + + + + + 6 + + + + 4 2 2 + + + 3 13
Douma, 2006 + + + + + + 6 2 + + + 3 + + + + 2 4 13
Douma, 2007 + + + + + + 6 2 + + + 3 + + + + + 5 14
Embregts, 2009 + 2 + + 2 + 4 2 2 + 2 1 2 + + + 2 3 8
Emerson, 2010 + + + + 2 + 5 + + + + 4 + + + + 2 4 13
Farhadifar, 2011 + 2 2 + + + 4 + + + + 4 2 + 2 2 2 1 9
Fenning, 2007 + + + + 2 + 5 2 2 + 2 1 + + + + 2 4 10
Fernell, 2010 + + + + + + 6 + + + + 4 + + + + + 5 15
Guralnick, 1987 + + + + + + 6 + + + 2 3 + + + + + 5 14
Hartman, 2010 + + + + + + 6 + + + 2 3 2 + + 2 + 3 12
Hassiotis, 2008 + + + + 2 + 5 + + + + 4 2 + + + 2 3 12
Hassiotis, 2011 + + + + 2 + 5 + + + + 4 + + + + + 5 14
Henry, 2001 + + + + 2 + 5 2 2 + 2 1 + + + + 2 4 10
Hollander, 1985 + + + + + + 6 + + + + 4 2 2 + + + 3 13
Karande, 2008 + + + + + + 5 + + + + 4 2 2 + 2 + 2 11
Kinge, 1979 a + + + + + + 6 + + + + 4 + + + + + 5 15
Kortteinen, 2009 + + + + 2 + 5 2 + + 2 2 + + + + 2 4 11
MacMillan, 1998 + + + + + + 6 + + + + 4 + 2 + + + 4 14
Maehler, 2009 + + + + 2 + 5 2 + + 2 2 + + + 2 2 3 10
Mähler, 2005 + 2 + 2 2 2 2 2 2 + 2 1 + 2 + 2 2 2 5
Marlowe, 1983 + + + + 2 + 5 + + + 2 3 + 2 + + 2 3 11
McAlpine, 1991 + + + + 2 2 4 2 2 + 2 1 + + + 2 2 3 8
Napora-Nulton, 2003 + 2 + + 2 + 4 2 + + 2 2 + + + + 2 4 10
O’Brien, 1996 + + + + 2 + 5 2 + + + 3 + + + + 2 4 12
Ramey, 1992 + + + + + + 6 + + + + 4 + + + + 2 4 14
Roberts, 1991 + + + + 2 + 5 2 2 + 2 1 + + + + 2 4 10
Schuchardt, 2010 + + + + 2 + 5 2 + + 2 2 + + + 2 2 3 10
Schuchardt, 2011 + + + + 2 + 5 2 + + 2 2 + + + 2 2 3 10
Schuster, 1982 + + + + + + 6 2 + + + 3 + 2 + + 2 3 12
Seltzer, 2005 + + + + 2 + 5 2 2 + + 2 + + + + + 5 12
Seltzer, 2009 + + + + 2 + 5 2 + + + 2 + 2 + + + 4 12
(Table 2 continued)
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2014, Vol. 52, No. 6, 419–443 DOI: 10.1352/1934-9556-52.6.419
Table 2
Continued
Informativity External validity Internal validity

Study (Lead Author) a b c d e f Subtotal g h i j Subtotal k l m n o Subtotal Total
Swanson, 1994 + + + 2 2 + 4 2 2 2 2 0 + + + + 2 4 8
Thompson, 1990 + + + + 2 + 5 2 2 + 2 1 + + + + 2 4 10
Vaillant, 2000 + + + + 2 + 5 2 2 + + 2 2 + + 2 + 3 10
Van der Meer, 2004 + 2 + + 2 + 4 2 + + 2 2 + + + + 2 4 10
van Nieuwenhuijzen,
2011 + + + + 2 + 5 2 + + 2 2 + + + 2 2 3 10
Vuijk, 2010 + + + + + + 6 2 + + 2 2 2 2 2 + 2 1 9
Westendorp, 2010 + + + + 2 + 5 2 + + 2 2 2 + 2 + 2 2 9
Zetlin, 1990 + 2 + + + + 5 + + + 2 3 + 2 + 2 2 2 10
Note. a) The purpose of the study is clearly described. b) The method of the data collection is properly
described. c) The main outcomes to be measured are clearly described in the introduction or methods section. d)
The description of the characteristics of the population is sufficient. e) The response rate is .70%, or the
information of the no responders is sufficient. f) The main findings of the study are clearly described: simple
outcome data should be reported for all major findings. g) The subjects asked to participate are representative for
the entire population from which they were recruited. h) The inclusion and exclusion criteria are described. i) The
age range is specified. j) The study period is described. k) The data are prospectively collected. l) A comparison
group is used and properly described. m) The measurement instrument(s) is/are described. n) The main outcome
measures used are accurate (valid and reliable). o) Age specific and gender specific outcomes are reported.
+ 5 Yes. 2 5 No.
a
Sample details from Svendsen, 1983.
Assessment Battery for Children. Both Hartman et al. and reading (Bonifacci & Snowling, 2008; Birch,
and Westendorp et al. studied gross motor skills. 2003; Maehler & Schuchardt, 2009; Napora-
They similarly found children with average intelli- Nulton, 2003; Swanson, 1994). The SLD group
gence outperforming students with BIF on both outperformed the BIF group in 10 out of 15
subscales. Westendorp et al. reported that, of the 12 measured skills. In five measures, the performance
skills studied, only three (hop, jump, throw) were at of both groups was at the same level. Differences
the same level of performance in the two groups. between groups were particularly clear regarding
Comparison of mild intellectual disability executive functioning because all the measures
(MID) and specific learning disabilities (SLDs). showed poorer performance among the BIF group.
Some of the above studies also reported results for
people with MID or SLDs. Six studies (see Table 3)
compared subjects with MID and BIF, mainly Social Behavior
covering areas of memory, motor, and academic Twelve studies focused on social interaction,
functioning (Hartman, et al. 2010; Henry, 2001; participation, or antisocial behavior. The method-
MacMillan et al., 1998; Schuchardt et al., 2010; ological quality scores of the studies (see Table 2)
Vuijk et al., 2010; Westendorp et al., 2011). Out of varied from 8 to 14 (mean 11.0). The number of
17 measured skills, the BIF group outperformed the subjects varied from 64 to 1556 (mean 323;
MID group in 11 skills and was at the same level in Table 1).
six skills. The difference between groups was clear Social interaction. Studies concerning peer
in memory and motor functioning, because the interaction showed more solitary play and less peer-
results mainly showed better performance among or group-play behavior among children with BIF
people with BIF than among those with MID. Five than among those in the average control groups
studies compared subjects with SLDs and BIF, (Guralnick & Groom, 1987; Roberts, Pratt, &
covering areas of memory, executive functioning, Leach, 1991). Peers seem to have a great impact on

428
Table 3
Studies, Criteria Used to Determine the BIF Group, Tests Used, and Outcomes of Academic and Cognitive Measures, in Detail
2014, Vol. 52, No. 6, 419–443
Results as compared tob

Recruitment of
Study the subjects a Measured skill AIF SLD MID Test(s) used
Alloway, 2010 1. Mainstream school Verbal memory poor N digit recall (AWMA)
2. a) IQ 70–85 N word recall (AWMA)
b) Not a nonverbal N nonword recall (AWMA)
learning disability N backward digit recall (AWMA)
N listening recall (AWMA)
INTELLECTUAL AND DEVELOPMENTAL DISABILITIES
N counting recall (AWMA)

Visuo-spatial memory poor N dot matrix (AWMA)
N block recall (AWMA)
N mazes memory (AWMA)
N Mr X (AWMA)
N spatial spam (AWMA)
N odd-one-out (AWMA
Executive functioning (shift poor N the trail making (D-KEFS)
attention, cognitive inhibition, N stroop (D-KEFS)
problem solving, N sorting (D-KEFS)
planning, response inhibition) N tower test (D-KEFS)
N walk-don’t walk (D-KEFS)
c
Atkinson, 1984 1. Special school Reading N (subject reads aloud: if he seems to
2. IQ 49–82 (notion, not a be poorer than 13 years old): Neale
criteria in this study) Analysis of Reading ability
(Table 3 continued)
’AAIDD
BIF Review
DOI: 10.1352/1934-9556-52.6.419
Table 3
Continued

Recruitment of
M. Peltopuro et al.
2014, Vol. 52, No. 6, 419–443
Birch, 2003 1. Mainstream school Phonological processing poor poor N Word Attack (WJ-III)
2. a) IQ 71289 N Spelling of Sounds (WJ-III)
b) Reading score low, N Sound Awareness (WJ-III)
but not the lowest Rapid naming poor poor N Retrieval Fluency (WJ-III)
possible (70–89) N Rapid Picture Naming (WJ-III)
Auditory processing poor poor N Incomplete Words (WJ-III)
N Auditory Attention (WJ-III)
N Sound Patterns-Music (WJ-III)

Memory poor poor N Auditory Working Memory (WJ-III)
N Understanding Directions (WJ-III)
Bonifacci & En: Reading poor same N Accuracy (en)
Snowling, 1. Special schools or N Speed (en & it)
2008 Centre for Reading Speed of processing poor poor N Simple RT
and Language N Choice RT
2. IQ 70285 N Number scanning
It: N Symbol scanning
1. Mainstream schools Sustained attention poor poor N Time limited cancellation test
2. IQ 70285 (Leiter-R)
Verbal short term memory poor same N Digit span forward (WISC-R)
N Digit span backward (WISC-R)
Claypool et al., 1. Archival data from Word recognition poor N WIAT or
2008 assessment center Math calculation poor N WRAT or
2. a) IQ 70279 N WJ-II or
b) not a significant N Canada Quiet
difference between
VIQ and PIQ
(Table 3 continued)
429
DOI: 10.1352/1934-9556-52.6.419
’AAIDD
Table 3
Continued
430
Recruitment of
Hartman et.al., 1. Primary special schools Locomotor skills (run, gallop, poor good N TGMD-2
2010 2. IQ 70–79 hop, leap, jump, slide)
N
2014, Vol. 52, No. 6, 419–443
3. no ADHD or autism or Object control (strike, bounce, poor same TGMD-2

conditions that affect catch, kick, throw)
motor competence Executive functioning (planning, poor same N Tower of London
decision-making, problem
solving)
Henry, 2001 1. Special schools Phonological memory poor same N Digit span
2. IQ 70279 N Word span
N
Visual- spatial memory same good Spatial span

N Pattern span
Complex memory same good N Listening span
N Odd one out span
Kortteinen et.al., 1. Mainstream schools Arithmetic poor N 56-item test of arithmetic skills
2009 2. a) poor school Phonology poor N Pig Latin task, Finnish counterpart
performance Spelling same/ N 20 dictated words
b) IQ 70–84 poor and nonwords
c) without RD (n533) Rapid naming same/ N RAN
and with RD (n529) poor
Reading comprehension poor N Text reading and answering to 11
multiple choice questions
Syntactic skills poor N Answering to questions with
complex syntactic structures
Text reading same/ N Reading text aloud 3 min
poor
Verbal memory poor N Logical memory (WMS-R)
N Associate learning (WMS-R)
Visual memory same N Visual reproduction (WMS-R)
N Visual recognition (WMS-R)
’AAIDD
BIF Review
DOI: 10.1352/1934-9556-52.6.419
(Table 3 continued)
Table 3
Continued
M. Peltopuro et al.
Recruitment of
2014, Vol. 52, No. 6, 419–443
MacMillan et.al., 1. Mainstream schools Arithmetic poor same N Arithmetic (WRAT-R)
1998 2. a) Poor school Reading poor good N Reading (WRAT-R)
performance Spelling poor same N Spelling (WRAT-R)
b) IQ 71285
Maehler & 1. Counseling center Working memory:
Schuchardt, 2. a) IQ 55–85 phonological poor same N Digit span
2009 b) Poor scholastic skills N 1- and 3 syllable word span

N 1 syllable nonword span
N Nonword repetition
Visuo-spatial poor same N Location span
N Corsi-block simple and complex
N Matrix span simple and complex
Central executive poor same N Backward digit span
N Backward word span
N Double span
N Counting span
Mähler, 2005 1. Special school Acquiring abstract theories poor N Story and related questions were
2. IQ 75 (mean) presented
N Three mechanism was proposed in a
forced choice test
Napora-Nulton, 1. Children’s behavioral Speed of processing: poor poor (to N Average reaction time (CCT)
2003 health clinic Processing novel stimuli errors) N Phase shift RT (CCT)
2. a) IQ 70–79 N Error rate (CCT)
b) Male
(Table 3 continued)
431
DOI: 10.1352/1934-9556-52.6.419
’AAIDD
432
Table 3
Continued

Recruitment of
2014, Vol. 52, No. 6, 419–443
Schuchardt 1. Special school Working memory:
et al., 2010 2. IQ 70284 Phonological poor good N Digit span
N 1-syllable nonwords
N Nonword repetition
Visuo-spatial poor good N Location span
N Corsi-block simple and complex
Central excutive poor good N Backward span

N Counting span
Swanson, 1994 1. Mainstream schools Learning strategies poor poor N Dynamic assessment
2. a) IQ 70290 Verbal memory poor poor N Rhyming task (CPT)
b) reading , 25th perc. N Auditory Digit sequence task (CPT)
c) math , 25th perc. Visual-spatial memory poor poor N Visual matrix task (CPT)
N Mapping/directions task (CPT)
Van der Meer 1. Special school Response inhibition same N Go-no-go test with fast ISI 1 sec
& Van der 2. a) IQ 73 (mean) N With medium ISI 4 sec
Meere, 2004 b) No behavioral/ N With slow ISI 8 sec
psychiatric problems
Vuijk et al., 1. Special school Motor performance: N MABC
d
2010 2. IQ 71284 manual dexterity poor good
d
ball skills poor good
static and
d
dynamic balance poor Good
(Table 3 continued)
’AAIDD
BIF Review
DOI: 10.1352/1934-9556-52.6.419
2014, Vol. 52, No. 6, 419–443 DOI: 10.1352/1934-9556-52.6.419
behavior: When children with BIF were paired with
learning disability (SLD), and mild intellectual disability (MID). All results described are significant. c Direct comparison to average subjects was not
Note. a 1. 5 recruitment place, 2. 5 inclusion criteria. b Individuals with BIF are compared to controls with average intellectual functioning (AIF), specific
made. It seems however, that performance was poorer, for example 17% of individuals with BIF were ‘‘semi-literate’’, 12% nonreaders. d Comparison
same-age average control children, twice as much
positive interaction was observed as when they
were compared with pairs of two children with BIF
(Guralnick & Groom, 1987).
Test(s) used
Fenning, Baker, Baker, and Crnic (2007) found
that mothers of children with BIF exhibited less
positive and less sensitive parenting than the
mothers of children in the groups with average or
significantly below average intelligence (IQ test
TGMD-2
TGMD-2
score , 70). These mothers were also the least

likely to display a style of positive engagement.
Although children with BIF did not behave more
problematically than children with average intelli-
N
gence in observational situations did, their mothers

MID
same
good
reported that they had more externalizing symp-

toms. According to the authors, the findings suggest
that parental understanding of the problems of
SLD
children with BIF is inadequate and is not on the

same level as, for example, the parental under-
standing of a child with mental retardation. The
poor
poor
authors concluded that children with BIF are at risk

AIF
for poor parenting.

Social information processing seems to differ
among children with BIF when they were compared
bounce, catch, kiack, throw,
with their peers. Embregts and van Nieuwenhuijzen

Locomotor skills (run, gallop,
Object control skills (strike,
(2009) and van Niuwenhuijzen, Vriens, Scheep-

hop, leap, jump, slide)
maker, Smit, and Porton (2011) studied children’s

Measured skill
responses to video vignettes describing demanding

social situations. Both studies reported mainly more
passive and/or aggressive and less assertive respons-
es in various social situations (e.g., generating
spontaneous responses to problems, evaluating
roll)
social situations, choosing from different ways to

made against the normative population of MABC test.
behave) for children with BIF than for children in

the control group.
McAlpine, Kendall, and Singh (1991) studied
the recognition of facial expressions in children
3. No ADHD or autism
with normal intelligence, borderline intelligence,

Recruitment of
the subjects a
and intellectual disability (ID). They found that

1. Special schools
children with BIF recognized all facial expressions

of emotion more frequently than their peers with
ID did, but less frequently than their peers with
2. 71279
average intelligence. Van Nieuwenhuijzen et al.

(2011) studied facial expressions as well and found
no difference between the groups in the recognition
of sad, happy, and angry expressions. However, fear
et al., 2011
was less recognized by the children with BIF than

Westendorp
Study
by their peers.
Continued
Table 3
Social participation. Seltzer et al. (2005) found

no differences in the frequency of meeting friends
and relatives between high school graduates with

2014, Vol. 52, No. 6, 419–443 DOI: 10.1352/1934-9556-52.6.419
BIF and their average-intelligence siblings in Hassiotis et al., 2008), mental health problems were
adulthood. Additionally, no differences were found more prevalent among subjects with BIF than among
in the proportions of people who had the opportu- the general population (Table 4). Although Dekker
nity to turn to friends, parents, siblings, or children and Koot did not include a control group in their
in times of trouble. The only difference between study, they concluded that the prevalence of most
groups was observed in the number of organizations mental disorders among subjects with BIF exceeded
participated in, with the BIF group participating in the prevalence that was observed in the general
fewer organizations than their siblings. population. Chen et al. found the current emotional
Antisocial behavior. Three studies showed the problems of people with BIF to be at the same level as
prevalence rates of BIF in different criminal those with ID. Emerson et al. also reported a similar
populations: 30% among adults in pretrial deten- prevalence of emotional and conduct problems
tion (Crocker, Gote, Toupin, & St-Onge, 2007), among children with BIF and with ID. In their study,
33% among juvenile criminal offenders (Schuster children with ID had higher levels of hyperactivity
& Guggenheim, 1982), and 47% among incarcer- and peer problems than the children with BIF did,
ated ‘‘hardcore’’ juveniles (Hollander & Turner, but they also showed more prosocial behavior.
1985). People with BIF seem to be overrepresented A different observation was made by Douma,
in populations of criminal offenders, because the Dekker, Verhulst, and Koot (2006) when they
presumed prevalence of BIF would be about 14%. studied self-reports on mental health problems of
Douma, Dekker, Ruiter, Tick, and Koot (2007) youth with BIF. When they compared the emo-
studied antisocial and delinquent behaviors in 526 tional and behavioral problem scores on the Youth
youths (aged 11 to 24 years) with BIF. Each type of Self-Report Scale of youths with BIF with the
behavior (mean to others, physical aggression, scores of their average peers, they found that the
theft/arson, property destruction, authority avoid- youths with BIF did not differ.
ance) was exhibited by roughly 10–20% of youths. Hassiotis, Tanzarella, Bebbington, and Cooper
Of these, physical aggression, theft/arson, and (2011) studied rates of suicidal behavior (thoughts
property destruction were seen more in the BIF and acts) among a large general population sample
group (19%, 12%, and 13%, respectively) than in of people with BIF. When people with BIF were
the general population group (13%, 6%, and 8%, compared with the general population, the people
respectively). Boys with BIF, but not girls, displayed with BIF were more likely to have attempted
antisocial behavior. suicide or to have harmed themselves. However,
Among the children with poor school perfor- these observations were likely not to be related
mance, the prevalence of behavioral disturbances specifically to BIF, because differences were no
was 94% for children with average intelligence and longer significant after controlling for income
86% for children with BIF (Thompson, Lampron, and age.
Johnson, & Eckstein, 1990). Mental health care. Hassiotis et al. (2008)
found that individuals with BIF were proportionally
Mental Health less likely to receive treatment for mental health
Six studies dealt with the issues of mental health. problems than the general population. When they
The results seem to be reliable, because the sample did receive treatment, they were more likely to be
sizes were large (474; 1,328; 1,681; 4,337; 6,872; treated with medication, and less likely to be
and 8,450), and the methodological quality of the treated with counseling. Dekker and Koot (2003)
studies varied from 12 to 14 (mean 12.8; see examined children and adolescents with BIF and
Tables 1 and 2). found 27% of those with diagnoses receiving
Prevalence. The prevalence of mental health professional help. The study did not include a
problems among people with BIF was reported in four control group, but authors concluded the preva-
studies (Chen, Lawlor, Duggan, Hardy, & Eaton, lence to be similar to rates found in the general
2006; Dekker & Koot, 2003; Emerson, Einfeld, & population of the same age.
Stancliffe, 2010; Hassiotis et al., 2008). Whether
comparing already existing diagnoses (Chen et al., Employment and Marriage
2006) or symptoms of the mental health problems The reliability of results of five studies dealing with
(Dekker & Koot, 2003; Emerson et al., 2010; employment and marriage were hampered by the
434 BIF Review

2014, Vol. 52, No. 6, 419–443 DOI: 10.1352/1934-9556-52.6.419
Table 4
Prevalence of Mental Health Problems in Persons With Borderline Intellectual Functioning (BIF) and Average
Intellectual Functioning (AIF)
%
Study Disorder BIF AIF
a
Chen et al., 2006 Current emotional problem 10 4
Current smoker b 51 46
Alcohol related problems b 26 19
Dekker & Koot, 2003 Anxiety 22
Phobia 17
Panic disorder 0
Obsessive-compulsive 3
disorder
Disruptive disorder 25
ADHD 15
ODD 14
CD 3
Mood disorder 4
Depressive 2
Dysthymic 2
Manic 0
Hypomanic 0
Comorbidity 36
Emerson et al., 2010 Total difficulties b 17 5
Conduct difficulties b 19 8
Emotional difficulties b 15 6
Hyperactivity b 15 8
Peer problems b 21 11
Prosocial behavior b 8 3
Hassiotis et al., 2008 Phobia b 3 2
Depressive episode b 4 2
Any neurotic disorder b 20 16
Any personality disorder b 37 27
Antisocial b 10 5
Avoidant b 11 5
Borderline b 15 5
Dependent b 7 0
Paranoid b 11 3
Psychosis 1 1
Comorbidity b 29 22
Alcohol dependence b 10 6
Drug dependence b 5 3
Note. a 150% increased risk of treatment for emotional problems in adulthood as compared to AIF. b Difference
between BIF and AIF is significant.

2014, Vol. 52, No. 6, 419–443 DOI: 10.1352/1934-9556-52.6.419
small sample sizes (see Table 1) and the age of the those married to their first spouse. In Kinge’s study
studies, three of which were over 2 decades old. (1979), 92% of women with BIF were married,
Recent figures on employment were available from which did not differ from women with average
only one study. intelligence. Atkinson (1984) found 70% of former
Employment. In the most recent study, Seltzer male pupils with BIF to be married. Hassiotis et al.
et al. (2005) studied 201 pairs of siblings, those (2008) found 56% of people with BIF and 70% of
with BIF and their siblings with average intelli- people with average intelligence were living as
gence, at ages 35 and 52. The employment rates did couples. The difference was likely to be due to the
not differ between the groups. However, occupa- BIF group having been considerably younger than
tional prestige at both ages and total earnings at age the group with average intelligence.
52 were significantly lower in the BIF group.
Subjects with BIF had also been employed longer
Risk and Preventive Factors
at their current jobs than siblings with average
The methodological quality of 11 studies dealing
intelligence. Kinge (1979) studied former pupils of
with risk or preventive factors varied greatly, with
classes for slow learners at age 30. He reported
scores from 6 to 14 points (mean 11.0; see Table 2).
employment rates of 81% for men and 8% for
The sample sizes also varied widely, from 11 to
women in the BIF group, and 94% for men and
1681 (mean 397; see Table 1).
41% for women in the average intelligence group.
Potential risk factors for BIF were identified
Of the married women, the proportion of house-
from seven studies. Based on three studies, the risk
wives was 83% in the BIF group and 62% in the
of BIF somewhat increased with low birth weight
average intelligence group. Of the working men,
(LBW). The prevalence of LBW in the adult BIF
the proportion working as unskilled workers was
50% in the BIF group and 19% in the average population was higher (24%) than in the average
intelligence group. In regards to the occupational intelligence population (13%) in the study of
status of the subjects with BIF, 19% were low- hospital birth cohorts (Chen et al., 2006). The
income earners. These proportions were larger than prevalence of BIF in the group of 3-year-old
among the subjects with average intelligence (6% children with LBW was 19% (Ramey et al.,
of men and 33% of women). Kinge did not report 1992). Another study reported 13% of 6-year-old
statistical analysis on the differences between the children with LBW as having BIF, which is the
groups. Atkinson (1984) studied former male pupils expected prevalence of BIF in the general popula-
of a special school in their fifties and found 85% of tion (Chaudhari, Bhalerao, Chitale, Pandit, &
them to be employed. Of them, 62% had held the Nene, 1999). However, the same children were
same job for over 20 years and 70% worked followed to age 12 and the prevalence of BIF was
unskilled or semiskilled jobs. Their average weekly found to increase to 24% (Chaudhari, Otiv,
wage was lower than that of the general population. Chitale, Pandit, & Hoge, 2004).
Zetlin and Murtaugh (1990) reported an observa- Within a group of 15 4-year-olds with BIF,
tion that differed from the above results when they poor family environment (including factors such as
followed adolescents with BIF before and after high poverty, being a member of a minority ethnic
school graduation. Although 80% of adolescents group, or living with a single parent) were present
had held at least one job during a period of two in 80% of the cases (O’Brien, Rice, & Roy, 1996).
years before graduation and one year after it, they A low level of education for the mother was present
had difficulty maintaining a job. They had held one in 76% of adults with BIF, compared with 68% in
to five jobs per person, with 1 month to 3 years the average intelligence population (Chen et al.,
being the longest time spent at one job. All jobs 2006). Exposure to toxic metals was detected as a
were unskilled or semiskilled. potential risk for BIF in randomly selected school
Marriage. Seltzer et al. (2005) found that, at children with BIF, of whom 36% presented
age 35, the rate of marriage was somewhat lower elevated levels of lead and 17% elevated levels of
among subjects with BIF than it was among their cadmium in comparison to 7% and 6%, respective-
siblings of average intelligence (89% vs. 94%, ly, in the control groups (Marlowe, Errera, &
respectively). Fifteen years later, such a difference Jacobs, 1983). Farhadifar et al. (2011) reported
was not found. There were also no differences in mother’s illiteracy, a familial history of ID, and
the number of children and in the proportion of maternal drug use during pregnancy as being more
436 BIF Review

2014, Vol. 52, No. 6, 419–443 DOI: 10.1352/1934-9556-52.6.419
common for children with BIF (78%, 25%, and neuropsychological, social, and mental health
21%, respectively) than for children in the control problems were evident. Although employment
groups with average intelligence (39%, 4%, and rates were relatively high, wages were lower than
7%, respectively). average. Low birth weight, negative family envi-
It seems that early developmental delays are ronment, mothers with low education levels, and
connected to BIF. O’Brien et al. (1996) reported toxic metals can be seen as risk factors for BIF.
73% of children with BIF as having delayed mental Preventive factors included education, social con-
or motor development, as compared with 42% in nections, and some personal qualities.
children in the control group. Because the preva- The purpose of the review was to collect
lence in the control group was so high, very mild literature concerning BIF in order to increase
developmental delays must have been included in knowledge about the problems related to BIF, to
the study. Another study reported 58% of children examine the prevailing situation in the field in the
with BIF to have either delayed walking or delayed light of current literature, and to bring the topic up
talking. Furthermore, 62% of children with BIF for discussion. Of the 1,726 original citations
showed some form of soft neurologic signs (Kar- yielded from database searches, only 49 studies
ande, Kanchan, & Kulkarni, 2008. The study did made it to the final sample of the review. This is an
not include a control group. astonishingly low number considering the nearly
Three preventive factors that seem to have a 14% prevalence of people with an IQ score of 70 to
positive effect on the life of those with BIF were 85. Fortunately, research interest seems to have
detected: education, social contacts, and personal grown in recent years. Since 2000, studies have
qualities. The positive influence of education was been carried out in 14 different countries, with
reported in three studies comprising favorable most of them occurring in the United States and
school records (Atkinson, 1984), education be- the Netherlands. Age groups from 2 to 74 years
yond high school (Seltzer et al., 2009), and more were represented. Among those studied, males were
years of education (Vaillant & Davis, 2000). The more represented than females. The quality of the
same studies also reported the positive effects of studies varied greatly.
social contacts, including supportive parents (At- In general, the information on BIF is fragmen-
kinson, 1984), role models for achievement tary. Based on the review, cognitive and academic
(Seltzer et al., 2009), and warm relationships difficulties are clear. Of the 52 skills measured, the
(Vaillant & Davis, 2000). Two studies reported performance by people with BIF was at the level of
personal qualities, including flexibility to change their average intelligence peers in only seven of
with situational demands (Atkinson, 1984), and them. With the exception of memory, only a few
childhood competence (including ego strength, studies in each area were found, and studies
perseverance, and relationship skills; Vaillant & concerning many relevant cognitive functions
Davis, 2000). It is not clear, however, whether the (e.g., conceptual learning) were unavailable.
personal qualities have caused the more successful The difficulties in neurocognitive functioning
life paths or vice versa. were consistently reported in relation to same-age
Only two studies on interventions for people peers. It is only in the area of memory functions
with BIF were identified. Early training with 3-year- that people with BIF were compared with others
old at-risk children showed a prevalence of BIF with a similar mental age, and the conclusion was
from 5% to 8%, compared with 19% for the control that memory functions were at the level of their
group without training (Ramey et al., 1992). general cognitive abilities (Schuchardt et al., 2010;
Adolescents with BIF showed improvement in Schuchardt et al., 2011). Using designs that utilize
acquiring community skills through the method of control groups with a similar mental age in other
combining specific written instructions with feed- areas of neurocognitive functioning would provide
back (Cuvo, Davis, O’Reilly, & Mooney, 1992). important information on the similarities and
differences between the development of subjects
Discussion with BIF and typically developing children. The
The review shows that many people with BIF face design might help to identify which aspect is
major difficulties across their life courses. When differentiating subjects: a developmental lag or
they were compared with the general population, qualitatively different functioning. These kinds of

2014, Vol. 52, No. 6, 419–443 DOI: 10.1352/1934-9556-52.6.419
studies are important for the sake of theoretical education have increased and the number of lower-
formulations and for intervention planning. skilled jobs has decreased, it has become more
People with BIF seem to differ from the average difficult for young adults with compromised intel-
population in terms of their social behavior. lectual functioning and related poor educational
Differences were seen in play behavior, social attainment to find employment.
information processing, recognition of emotions, In general, the studies reported high employ-
social participation, and antisocial behavior. Chil- ment rates for subjects with BIF. Kregel (2001)
dren with BIF also seem to be at risk for poor reported contrary unemployment rates of 70%–80%
parenting. In addition, subjects with BIF were for individuals with mild cognitive limitations (IQ
found to be overrepresented in criminal samples. As test score of 55–84). The rather encouraging high
compromised learning skills put children and employment rates in the present review may prove
adolescents with BIF at risk for poor school too optimistic, because current studies with repre-
performance, they are at a higher risk for alienation sentative samples were unavailable. Two studies
or antisocial behavior than their peers. examined high school graduates (Seltzer et al.,
The prevalence of mental health problems 2005; Zetlin & Murtaugh, 1990), and the samples
among people with BIF was repeatedly reported as in these studies are not likely to be representative of
being higher than in the general population. This the whole population with BIF. Instead, they
finding is in line with several studies that have represent only those with strong scholastic apti-
reported mental health problems as being more tude. Two other studies were relatively old
common among people with mild levels of ID (Atkinson, 1984; Kinge, 1979), and it is question-
(Koenen et al., 2009; Linna et al., 1999; Wallander, able how well their results generalize to modern job
Dekker, & Koot, 2003). The results of one study on markets. Kinge reported in 1979 that 92% of
mental health contradicted the other reviewed Norwegian women with BIF were housewives. This
studies. The study found self-reports of psychiatric is likely not today’s reality, at least not in
symptoms in youths with BIF to be similar to those Scandinavia, where equality in the job market has
with average intelligence (Douma et al., 2006). been established and being a housewife is no longer
The authors concluded that the results were in the norm.
contrast to the commonly found higher rates of The causes of BIF are unknown. There need
psychiatric symptoms in people with lower intelli- not even be an actual cause, because BIF can be
gence, but addressed that usually the results rely on seen as part of the normal variation, with IQ being
parent or teacher reports, not on self-reports. at the lower range of the normal distribution. The
However, of the other reviewed studies, Hassiotis reported risk factors for BIF (low birth weight,
et al. (2008; 2010) also used self-reports and, thus, mothers with low education, negative family
the use of a self-report does not seem to be the sole environment), as well as those factors reported to
reason for the results reported by Douma et al. Age protect people from adverse outcomes (education,
differences between the adult subjects in the studies social connections, and some personal qualities),
by Hassiotis et al. and the adolescent subjects in the were general and certainly not specific to people
study by Douma et al. might partly explain the with BIF.
difference, because it is possible that adolescents do The results of studies of cognitive skills
not recognize their problems as readily as adults. comparing BIF and MID or BIF and SLD show
Four studies on employment consistently that BIF seems to fall somewhere between the two
reported that people with BIF, when they were categories, because people with BIF mostly had a
compared with the general population, held lower- better performance level than those with MID and
skilled jobs, earned lower wages, and had longer a worse level than those with SLD. It is possible
careers in the same job. Although the adults studied that, due to the subject recruitment process,
had mostly found their places in the job market, learning difficulties are overrepresented in BIF
adolescents struggled to find and keep a job. This groups studied, which may affect the results. There
difference may imply that the transition from are no comparisons between these three groups that
adolescence to adulthood is problematic for young consider the amount of support needed or received
people with BIF. It may also reflect changes in the in real life. It can, however, be speculated that the
labor market, at least in Western societies. One BIF group is in a worse situation than the other two.
possible assumption is that, as the requirements for Because the problems with BIF are not as visible as
438 BIF Review

2014, Vol. 52, No. 6, 419–443 DOI: 10.1352/1934-9556-52.6.419
those in MID and not as specific as those in SLDs, population, struggle with many aspects of life. To
they often go unrecognized and, consequently, no enable the full inclusion and participation of
support is offered. persons with BIF in society, it is crucial to recognize
In general, the findings of the review showed that the difficulties that lower-than-average intellectual
the performance level of people with BIF is typically abilities produce in, for example, vocational
worse than that of their average intelligence peers and education and job training, and in developing
better than that of people with MID. The relationship services to accommodate these needs. With the
between these groups can be understood as one of right kind of timely support, people with BIF could
being on different points of a continuum of find their place in society and labor markets.
intellectual abilities. However, social support and
services do not form a similar continuum, but are
Limitations of the Study
delivered on a yes-or-no basis. In order to be eligible
It is possible that some relevant studies were not
for services, certain criteria have to be fulfilled. The
included in the review due to the wide range of
critical criterion in the area of compromised intel-
terms in the field used to describe the phenomenon.
lectual abilities is receiving a diagnosis of ID. If that
This possibility was minimized by searching
criterion is met, services are readily provided, income
through relevant journals and through the refer-
(at least in Finland) is guaranteed with a pension, and
ence lists of the included studies.
expectations for excelling at school and in the labor
BIF was defined solely on the basis of IQ test
market are lowered. For people with BIF who do not
qualify for those services, the expectations for score, without taking into account other functional
learning and independent living are similar to those aspects. Although this definition is far from perfect,
of others, yet their lower intellectual abilities and a systematic review would have been impossible to
related learning problems and less-than-optimal conduct without clear and globally used criteria.
adaptive skills hamper their success in these areas.
Social support lies behind cut-off lines, in this case Conclusions
behind a diagnosis of ID. Those just above the cut-off Despite the obvious, everyday problems that people
line do not have access to help and face high with BIF face, the issue seems to be almost invisible
performance expectations. in the field of research. There is a need for
The current literature shows that there is a longitudinal and population-based studies focusing
large group of people that need support in multiple on people with BIF. More research on the nature of
areas of life. The decision made a few decades ago BIF is needed (e.g., is it a qualitatively different
to exclude borderline intellectual disability from ID functioning or a developmental lag that explains
diagnoses has had, and continues to have, a huge the differences between subjects?). The critical life
impact on the lives of people with BIF. The periods to study are the transitions from compulsory
decision was affected by the possible stigma related school to secondary school and from secondary
to ID and concerns about overrepresentation of school to the labor market, because these are the
ethnic groups and poverty in the category of those points at which adolescents seem to struggle.
with a mild level of ID. However good the In addition, societal discussions of BIF are
intentions were, the decision excluded people with needed. People with BIF are left without official
BIF from existing services and, since then, no services in society because they often do not meet
official substitutive service has been introduced. For the criteria for special services. In reality, they often
current policy makers, an important first step would struggle with the demand to be ‘‘normal.’’ There is a
be to acknowledge the existence of this group. The major need for flexible support systems that are
second step should be to decide what actions to based on real needs.
take concerning services targeted at BIF. At the
moment, there are no official positions regarding
BIF or resources appointed for it. This gap leaves References
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http://dx.doi.org/10.1080/09297040490911005 This study was funded by the Finnish Slot Machine
*van Nieuwenhuijzen, M., Vriens, A., Scheep- Association and Finnish Cultural Foundation, Häme
maker, M., Smit, M., & Porton, E. (2011). The Regional Fund. The authors wish to thank Heli
development of a diagnostic instrument to Numminen and Hanna Kortteinen for their earlier
measure social information processing in chil- work with the topic, Pekka Kuikka for his ideas
dren with mild to borderline intellectual concerning the topic, Tuuli Kiljala for her assistance in
disabilities. Research in Developmental Disabilities: the acquisition of the articles, and Anneli Sintonen for
A Multidisciplinary Journal, 32(1), 358–370. her help with organizing the data.
http://dx.doi.org/10.1016/j.ridd.2010.10.012
Verdonschot, M. M. L., de Witte, L. P., Reichrath,
Authors:
E., Buntinx, W. H. E., & Curfs, L. M. G.
Minna Peltopuro, Timo Ahonen, and Jukka
(2009). Community participation of people
Kaartinen, University of Jyväskylä, Jyväskylä, Fin-
with an intellectual disability: a review of
land; Heikki Seppälä, FAIDD, Helsinki, Finland;
empirical findings. Journal of Intellectual Dis-
and Vesa Närhi, University of Eastern Finland,
ability Research, 53(4), 303–318. http://dx.doi.
Joensuu, Finland and Niilo Mäki Institute, Jyväs-
org/10.1111/j.1365-2788.2008.01144.x
kylä, Finland.
*Vuijk, P. J., Hartman, E., Scherder, E., & Visscher,
C. (2010). Motor performance of children with
mild intellectual disability and borderline Correspondence concerning this article should be
intellectual functioning. Journal of Intellectual addressed to Minna Peltopuro, Uimalaitoksenkatu
Disability Research, 54(11), 955–965. http://dx. 6, Riihimäki, 11130, Finland (email: minna@
doi.org/10.1111/j.1365-2788.2010.01318.x peltopuro.fi).

2014, Vol. 52, No. 6, 496–497 DOI: 10.1352/1934-9556-52.6.496
Résumés en Français
Disparités de nationalités et de santé chez les révèle que malgré les problèmes quotidiens évi-
adultes ayant une déficience intellectuelle et dents, le FIL est presque invisible dans le domaine
développementale vivant aux États-Unis de la recherche. Plus de recherches, de débats de
société et de systèmes de support flexibles sont
Haleigh M. Scott et Susan M. Havercamp
nécessaires.
La recherche a documenté des disparités dans les
soins de santé et dans l’accessibilité pour les Plus qu’une mammographie : dépistage du cancer
personnes ayant une déficience intellectuelle (DI) du sein et perspectives des proches de femmes
et les personnes faisant partie de minorités raciales ayant une déficience intellectuelle
et ethniques. Bien que ces deux populations soient
peu desservies, la combinaison de l’effet d’être un Nechama W. Greenwood, Deborah Dreyfus et
membre d’une minorité raciale/ethnique et d’avoir Joanne Wilkinson
une DI est largement méconnue. Cette étude utilise Les femmes ayant une déficience intellectuelle (DI)
les données d’une enquête nationale représentative présentent des taux similaires de cancer du sein que
pour explorer l’utilisation des services de santé la population générale, mais présentent une plus
parmi les adultes ayant une DI appartenant à un grande mortalité due à ce type de cancer ainsi que
groupe racial/ethnique minoritaire en comparaison des taux plus bas de dépistage régulier par
avec les adultes ayant une DI étant caucasiens. Les mammographie. Les taux de dépistage sont les plus
résultats de cette étude indiquent que les membres bas pour les femmes vivant avec leurs familles. Bien
de minorités raciales/ethniques sont désavantagés que les femmes ayant une DI prennent souvent
dans plusieurs sphères essentielles de l’accès aux leurs décisions avec leurs proches, un manque de
soins de santé et que les Américains d’origine recherche en lien avec la perspective des membres
hispanique sont particulièrement peu desservis. de la famille quant à la mammographie est observé.
D’autres études seront nécessaires afin d’identifier Une recherche qualitative a été faite au sujet des
et d’aborder les facteurs menant à cette différence. membres de la famille de femmes ayant une DI,
avec un guide d’entrevue se centrant sur les
Fonctionnement intellectuel limite : une revue décisions et les expériences en matière de soins de
systématique des écrits scientifiques santé, ainsi que sur les barrières, les facilitateurs et
les croyances reliées à leur être cher. Seize membres
Minna Peltopuro, Timo Ahonen, Jukka
de familles ont participé à des entrevues semi
Kaartinen, Heikki Seppälä et Vesa Närhi
structurées. Les thèmes principaux comprenaient la
Les écrits scientifiques relatifs aux personnes ayant mammographie en tant que point de référence pour
un fonctionnement intellectuel limite (FIL) ont été d’autres préoccupations socioculturelles, tels que la
systématiquement étudiés afin de résumer l’état sexualité de leur être cher ou ce que cela signifie
actuel des connaissances. Les recherches dans les pour eux d’être une femme adulte; la peur d’avoir à
bases de données ont mis en évidence 1 726 prendre des décisions difficiles s’il y avait un cancer
citations, et 49 études ont été incluses dans la revue de diagnostiqué en tant que barrière au dépistage de
des écrits scientifiques. Les personnes ayant un FIL ce dernier; une attention particulière à la qualité de
font face à une variété de difficultés dans la vie, y vie; et le désir que l’être cher reçoive des soins de
compris des problèmes neurocognitifs, sociaux et de santé de qualité, bien que la qualité des soins n’aille
santé mentale. Lorsque les adultes ayant un FIL ont pas automatiquement de pair avec un dépistage
été comparés à la population générale, ils occupai- régulier du cancer. Les adultes ayant une DI sont
ent des emplois demandant des habiletés moindres estimés par les membres de leur famille, et leurs
et gagnaient moins d’argent. Bien que certains proches sont investis dans leur bien-être. Les
facteurs de risque (par exemple, le faible poids à la familles craignent toutefois les décisions potentiel-
naissance) et facteurs de prévention (par exemple lement compliquées associées à un diagnostic de
l’éducation) aient été signalés, ils n’étaient pas cancer et peuvent choisir de renoncer au dépistage
spécifiques au FIL. La revue des écrits scientifiques en raison d’une mauvaise information et d’un
496 Résumés en Français

2014, Vol. 52, No. 6, 498–499 DOI: 10.1352/1934-9556-52.6.498
Resúmenes al Español
Raza y Disparidades de Salud en Adultos con FIL es casi invisible en el campo de la investiga-
Discapacidades Intelectuales y de Desarrollo que ción. Es necesario una mayor investigación, discu-
Viven en Estados Unidos sión social y sistemas flexibles de apoyo.
Haleigh M. Scott y Susan M. Havercamp
Más que una Mamografı́a: Perspectivas de Detec-
La investigación ha documentado las diferencias ción de Cáncer de Mama de Familiares de Mujeres
en la atención de salud y el acceso para las con Discapacidad Intelectual
personas con Discapacidades Intelectuales y de
Desarrollo (DID) y las personas en grupos de Nechama W. Greenwood, Deborah Dreyfus, y
minorı́as raciales y étnicas. Aunque ambas pobla- Joanne Wilkinson
ciones son marginadas, el impacto aditivo de ser a Las mujeres con Discapacidad Intelectual (DI)
la vez miembro de una minorı́a racial / étnica y tienen tasas similares de cáncer de mama a las del
tener DID en gran parte es desconocido. Este público en general, pero más alta mortalidad por
estudio usa datos de una encuesta representativa a cáncer de mama y más bajas tasas de chequeo
nivel nacional para explorar la utilización de regular a través de mamografı́as. Las tasas de
servicios de salud entre los adultos con DID detección son más bajas entre las mujeres que
pertenecientes a grupos minoritarios raciales / viven con sus familias. Aunque las mujeres con DI a
étnicos en comparación con los adultos blancos menudo toman decisiones en conjunto con sus
con DID. Los resultados de este estudio indicaron familiares, carecemos de investigaciones relaciona-
que los grupos minoritarios raciales / étnicos se das con las perspectivas familiares acerca de la
encuentran en una desventaja en varias áreas mamografı́a. Conducimos un estudio cualitativo de
esenciales de la utilización de servicios de salud y los miembros de la familia de mujeres con DI, con
que los Hispanos Americanos son particularmente una entrevista guı́a que se centró en la toma de
marginados. Es necesaria investigación adicional decisiones del cuidado de la salud y de las
para identificar y abordar los factores que impulsan experiencias, y las barreras de detección de cáncer
esta diferencia. de mama, los facilitadores y las creencias en
relación con sus seres queridos. Dieciséis miembros
Funcionamiento Intelectual Limı́trofe: Una Revi- de la familia fueron sometidos a entrevistas
sión Sistemática de la Literatura semiestructuradas. Los temas importantes in-
cluyeron la mamografı́a como un punto de refer-
Minna Peltopuro, Timo Ahonen, Jukka
encia para otras preocupaciones sociales y cultur-
Kaartinen, Heikki Seppälä, y Vesa Närhi
ales, como la sexualidad de su seres queridos o lo
La literatura relacionada a las personas con que significa ser una mujer adulta; el miedo de tener
Funcionamiento Intelectual Limı́trofe (FIL) fue que tomar decisiones difı́ciles, el cáncer que se
revisado sistemáticamente a fin de resumir el diagnostica actuando como una barrera para
conocimiento actual. Las búsquedas en bases de realizarse chequeos regulares; un foco en la calidad
datos produjeron 1.726 citas, y 49 estudios fueron de vida; y el deseo de atención de salud de calidad
incluidos en la revisión. Las personas con FIL se para sus seres queridos, aunque una atención de
enfrentan a una variedad de adversidades en la vida, calidad no siempre equivale a exámenes regulares
incluyendo problemas neurocognitivos, sociales, y de cáncer. Los adultos con DI son valiosos
de salud mental. Cuando los adultos con FIL fueron miembros de sus familias, y sus familiares están
comparados con la población general, ellos soste- dedicados a su bienestar. Sin embargo, las familias
nı́an bajas habilidades laborales y ganaban menos temen potencialmente a las decisiones asociadas
dinero. Aunque algunos factores de riesgo (por con un diagnóstico de cáncer y pueden optar por
ejemplo, bajo peso al nacer) y factores preventivos renunciar a la detección debido a la desinformación
(por ejemplo, educación) fueron reportados, no y un enfoque sobre la calidad de vida. Las
eran especı́ficos para el FIL. La revisión encuentra intervenciones efectivas para abordar las dispari-
que, a pesar de los obvios problemas cotidianos, el dades en la mamografı́a debieran centrarse en
498 Resúmenes al Español

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INTELLECTUAL AND DEVELOPMENTAL DISABILITIES ’AAIDD

2014, Vol. 52, No. 6, 419–443 DOI: 10.1352/1934-9556-52.6.419

Borderline Intellectual Functioning: A Systematic

M. Peltopuro et al. 419

420 BIF Review

Methods Intellectual Disabilities, and Journal of Intellectual

Eligibility Criteria Study Selection Process

M. Peltopuro et al. 421

422 BIF Review

M. Peltopuro et al. 423

Figure 1. Flowchart of the study selection process.

424 BIF Review

M. Peltopuro et al. 425

Informativity External validity Internal validity

426 BIF Review

Informativity External validity Internal validity

M. Peltopuro et al. 427

Results as compared tob

N counting recall (AWMA)

Results as compared tob

N Sound Patterns-Music (WJ-III)

3. no ADHD or autism or Object control (strike, bounce, poor same TGMD-2

Visual- spatial memory same good Spatial span

2009 b) Poor scholastic skills N 1- and 3 syllable word span

Results as compared tob

Central excutive poor good N Backward span

behavior: When children with BIF were paired with

score , 70). These mothers were also the least

gence in observational situations did, their mothers

reported that they had more externalizing symp-

children with BIF is inadequate and is not on the

authors concluded that children with BIF are at risk

for poor parenting.

with their peers. Embregts and van Nieuwenhuijzen

Object control skills (strike,

(2009) and van Niuwenhuijzen, Vriens, Scheep-

maker, Smit, and Porton (2011) studied children’s

responses to video vignettes describing demanding

social situations, choosing from different ways to

behave) for children with BIF than for children in

with normal intelligence, borderline intelligence,

and intellectual disability (ID). They found that

children with BIF recognized all facial expressions

average intelligence. Van Nieuwenhuijzen et al.

was less recognized by the children with BIF than

Social participation. Seltzer et al. (2005) found

M. Peltopuro et al. 433

434 BIF Review

M. Peltopuro et al. 435

436 BIF Review

M. Peltopuro et al. 437

438 BIF Review

M. Peltopuro et al. 439

borderline intellectual functioning. Journal of 477–489. http://dx.doi.org/10.1901/jaba.1992.

440 BIF Review

M. Peltopuro et al. 441

442 BIF Review

M. Peltopuro et al. 443

496 Résumés en Français