European Neuropsychopharmacology (2014) 24, 1793–1797

www.elsevier.com/locate/euroneuro

Borderline intellectual functioning

is associated with poor social functioning,
increased rates of psychiatric diagnosis
and drug use – A cross sectional population
based study
Karny Gigib, Nomi Werbeloffa, Shira Goldberga,
Shirly Portuguesec, Abraham Reichenbergd, Eyal Fruchterc,
Mark Weisera,b,n

a
Department of Psychiatry, Sheba Medical Center, Tel Hashomer 52621, Israel
b
Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
c
Division of Mental Health, Medical Corps, IDF, Israel
d
Department of Psychological Medicine, Institute of Psychiatry, London, England, United Kingdom

Received 18 February 2014; received in revised form 27 July 2014; accepted 30 July 2014

KEYWORDS
Borderline intellec-
tual functioning;
Social functioning;
Drug use;
Psychiatric diagnosis
Abstract
Borderline intellectual functioning is defined by the DSM IV as an IQ range that is between one
to two standard deviations below the mean (71oIQo84), and a considerable percentage of the
population is included in this definition (approximately 13.5%). The few studies performed on
this group indicate that borderline intellectual functioning is associated with various mental
disorders, problems in everyday functioning, social disability and poor academic or occupa-
tional achievement. Using data from the Israeli military, we retrieved the social and clinical
characteristics of 76,962 adolescents with borderline intellectual functioning and compared
their social functioning, psychiatric diagnoses and drug abuse with those of 96,580 adolescents
with average IQ (70.25 SD from population mean). The results demonstrated that the
borderline intellectual functioning group had higher rates of poor social functioning compared
to the control group (OR =1.9, 95% CI =1.85–1.94). Individuals with borderline intellectual
functioning were 2.37 times more likely to have a psychiatric diagnosis (95% CI =2.30–2.45) and
1.2 times more likely to use drugs (95% CI =1.07–0.35) than those with average IQ. These results
suggest that adolescents with borderline intellectual functioning are more likely to suffer from
psychiatric disorders, poor social functioning and drug abuse than those with average

n
Corresponding author at: Department of Psychiatry, Sheba Medical Center, Tel Hashomer 52621, Israel. Tel.: +972 52 666 6575;
fax: +972 3 6358599.
E-mail address: mweiser@netvision.net.il (M. Weiser).

http://dx.doi.org/10.1016/j.euroneuro.2014.07.016
0924-977X/& 2014 Published by Elsevier B.V.
1794
intelligence, and that borderline intellectual functioning is a marker of vulnerability to these
poor outcomes.
& 2014 Published by Elsevier B.V.
1. Introduction
Borderline Intellectual Functioning is defined by the DSM IV as
an IQ range that is higher than that of “mental retardation” –
between one to two standard deviations below the mean
(71oIQo84), encompassing 13.5% of the population. Few
investigators have studied the impact of borderline intellectual
functioning on psychiatric and social outcomes, partially due to
the fear that such studies might have the unintended conse-
quence of stigmatizing such individuals. Further, there are few
population based databases that include IQ and such outcomes,
and no longitudinal data regarding this vulnerability. None-
theless, existing data support the association between border-
line intellectual functioning and poor psychosocial outcome.
Hassiotis et al. (2008) examined data from the UK Wide Cross
Sectional Survey of 8450 adults living in private households.
They found that 12.3% of the sample had borderline intellectual
functioning, and compared to their peers with average intelli-
gence, this group had increased rates of neurotic disorders,
depressive episodes, phobias, substance misuse and personality
disorders, but not psychotic disorders. Further, this group was
more likely to receive psychiatric medications and to utilize
more community and daycare services. Seltzer et al. (2005)
compared individuals with IQ scores of 85 or below with their
siblings who obtained IQ scores above 100. They found that low-
IQ individuals completed less schooling, had less prestigious
occupations, rated themselves less physically healthy, and
reported lower levels of psychological well-being.
Some studies indicate that low IQ is associated with risky
health behaviors, such as alcohol abuse, and cigarette smoking
(Kubicka et al., 2001; Chandola et al., 2006; Weiser et al.,
2010). Other studies have demonstrated an association between
low intelligence and delinquency in adolescence (White et al.,
1989) and criminality or violence in adulthood (Huesmann
et al., 2002). Finally, in a recent study, Hassiotis et al. (2011)
demonstrated that participants with borderline intellectual
functioning were more likely to report suicide attempts or
self-harm compared to those with average intellectual func-
tioning. However these associations were no longer significant
after controlling for income and age.
In the current study we used a population-based dataset
collected by the Israeli Draft Board of 16–17 year old men to
identify a cohort of 76,962 with borderline intellectual func-
tioning and 96,580 with average IQs. The analyses examined
clinical and social characteristics (social functioning, psychiatric
diagnosis and drug use) of subjects with borderline intellectual
functioning compared to subjects with average IQ.
2. Experimental procedures
2.1. Draft board assessment
Israeli law requires that all adolescents between the ages of 16 and 17
undergo a pre-induction assessment to determine their intellectual,
K. Gigi et al.
medical, and psychiatric eligibility for military service. This assessment
is compulsory and is administered to the entire unselected population of
Israeli male adolescents. It includes individuals who are eligible for
military service, as well as those who will ultimately be excluded from
service for medical, psychiatric, or social reasons.
2.2. Cognitive assessment
The cognitive test battery yields a total score which is a highly valid
measure of general intelligence, equivalent to a normally distrib-
uted IQ score. Tests are administered by a trained psychometrician.
The cognitive assessment comprises four sub-tests: (a) Arithmetic-
R, which assesses cognitive reasoning, concentration, and concept
manipulation. This sub-test is similar to the ‘arithmetic’ sub-test
from the Wechsler Intelligence Scales. The test is in a multiple-
choice format and contains twice as many items, and therefore
includes harder test items; (b) Verbal analogies which assess verbal
abstraction and categorization (i.e. the ability to understand the
relationship between words and the use of this relationship in
several contexts). This is a multiple-choice test. This test is similar
to the ‘similarities’ sub-test from the Wechsler Intelligence Scale.
Unlike the Wechsler test, this sub-test is a multiple choice test and
subjects are requested not only to identify and report the semantic
of causal relationships between the test items, but also to apply
these relations to target items; (c) A non-verbal spatial analogies
test which measures non-verbal abstract reasoning and problem-
solving abilities. This test is also a multiple-choice test; (d) OTIS-R,
a modified, Otis-type verbal intelligence test adapted from the US
Army Alpha Instructions Test, which measures the ability to under-
stand and carry out verbal instructions (Lezak, 1995). Tests are
progressive, beginning with relatively simple items and becoming
more difficult. Tests are group-administered and are time-limited.
All scores are based on the number of correct answers. In many
validation studies conducted by the Draft Board, the summary score
of the cognitive test battery has been found to be a highly valid
measure of general intelligence (Gal, 1986)
2.3. Draft board psychiatric assessment
After the cognitive assessments are performed, a semi-structured,
thirty minute, interview is held. The purpose of the interview is to
assess personality and behavioral traits that will lead to an
estimation of the potential conscript's suitability for military
service, particularly service in combat units (Gal, 1986). The
interview is administered by trained enlisted individuals (most of
them female soldiers) who participated in a 3 month training
course. The interviewers are under regular supervision by senior
interviewers and participate in ongoing training. The behavioral
assessment, administered only to males, includes a subscale asses-
sing current social functioning. Based on structured questions,
social functioning is then scored on a scale of 1–5: (1) Very poor:
complete withdrawal, (2) Poor: weak interpersonal contacts,
(3) Adequate: can form relationships with individuals and in a
group, (4) Good: good interpersonal relationships and (5) Excep-
tional: superior interpersonal relatedness. The test–retest reliabil-
ity of the behavioral assessment for inductees interviewed after
several days by different interviewers is above 0.8, and population-
based norms are available (Reeb, 1968; Gal, 1986). The draft board
screening is described in detail in other reference (Gal, 1986).
Borderline intellectual functioning 1795

After this initial screening interview, potential conscripts who
are deemed to have significant behavioral problems (approximately
15–20% of those screened) are referred for an in-depth psychosocial
assessment. The in-depth psychosocial assessment is performed by
a postgraduate (MA) level clinical social worker or psychologist.
Drug abuse is systematically asked about in the initial screening
interview only for those male adolescents who are suspected of
having significant behavioral problems, before being referred for
the in-depth psychosocial assessment.
The criteria for referral for the in-depth psychosocial assessment
include one or more of the following: (a) obtaining the lowest score
on the rating of social functioning, (b) documentation or self-report
of present or past psychiatric symptoms, including enuresis, sleep
disturbances, drug or alcohol abuse; (c) clinical judgment of the
interviewer that the adolescent will not adapt well to the demands
of the military.
If the interviewer suspects that the adolescent has a psychiatric
disorder, he is referred to a board certified psychiatrist for
evaluation and an ICD-9 diagnosis. Diagnoses during the time
covered by this study were based on ICD-9 criteria, and were
divided into non-affective psychotic disorders, and non-psychotic
diagnoses grouped for purposes of the study to: neurosis, minor
affective disorders, anxiety disorders and PTSD; Adjustment dis-
order; Personality disorders; Anti-social personality disorder, sub-
stance abuse; Schizophrenia spectrum; Major affective disorders.
For more detailed description of the Draft Board assessment
procedure see (Gal, 1986).
2.5. Data analysis
Logistic regression was used to calculate the association between IQ
group (borderline intellectual functioning vs. average IQ) and social
functioning, yielding odds ratios and 95% confidence intervals. As
socioeconomic status (SES) is strongly associated with cognitive
ability and IQ (Noble et al., 2005), all analyses controlled for SES.
Multinomial regression was used to calculate the association
between IQ group and psychiatric diagnosis.
As psychiatric illness is associated with low IQ, poor social
functioning and drug abuse (Weiser et al., 2003, 2004, 2007;
David et al., 2008), we also stratified the analyses according to
the presence of psychiatric illness at the draft board assessment.
For the purpose of this analysis, social functioning was treated as a
dichotomous variable, using the median as a cut-off point for
coding, thus comparing those with very poor or poor social
functioning with those who had adequate, good or superior social
functioning.
Analyses were performed with SPSS 18.
3. Results
The mean IQ score of the borderline intellectual functioning
group was 79.5 (SD = 4.18) and of the control group 97.89
(SD =0.96).

3.1. Social impairment

2.4. Analytic sample
654,173 Male adolescents were consecutively assessed by the Draft
Board. Adolescents with missing IQ score (n=669, 0.1%) or with
missing SES (n=154,352, 23.5%) were excluded, leaving 499,766
adolescents.
Borderline intellectual functioning was defined as an IQ in the
range of 71–84; 76,962 (15.3%) adolescents were identified as
having borderline intellectual functioning.
In order to compare the borderline intellectual functioning group to
a group of subjects with the mean IQ in the population, we selected
those with an IQ between 96 and 104 (70.25 SD) controls. This IQ
range was selected in order to ensure that the lower boundary of the
average IQ group would be significantly higher than the best function-
ing individuals of the borderline intellectual functioning sample so that
the average IQ group will represent individuals around the mean
population IQ (19.7% according to the normal distribution probability).
Thus, 96,580 (19.3%) adolescents were included in the control group.
Logistic regression analyses controlling for SES revealed that
the borderline intellectual functioning group had higher
rates of poor social functioning compared to the control
group (31% in the borderline intellectual functioning group
as compared to 18% in the control group; OR = 1.9, 95%
CI= 1.85–1.94). When removing individuals with psychiatric
illness from the analyses, the association between border-
line intellectual functioning and poor social functioning was
mostly unchanged (OR= 1.78, 95% CI= 1.73–1.83).
3.2. Psychiatric diagnosis
Logistic regression analyses controlling for SES revealed that
individuals with borderline intellectual functioning were
2.37 times more likely to have any psychiatric diagnosis
than those with average IQ (95% CI= 2.30–2.45). The results

Table 1 The prevalence of psychiatric disorders among the borderline intellectual functioning group and control group.

Variable Borderline intellectual Average IQ group (n, %) Odds ratio (CI)

functioning group (n, %)

No psychiatric diagnosis 65,441, 85.7% 89,828, 93.2% –

Schizophrenia spectrum 175, 0.2% 86, 0.1% 2.498 (1.916–3.255)
Anti-social PD, 367, 0.5% 125, 0.1% 3.784 (3.073–4.658)
Substance abuse 86, 0.1% 85, 0.1% 1.209 (0.888–1.645)
Major affective disorder 210, 0.3% 119, 0.1% 2.016 (1.601–2.539)
Neurosis, minor affective 1417, 1.9% 1202, 1.2% 1.663 (1.535–1.802)
and anxiety, PTSD
Personality disorders 7815, 10.2% 4455, 4.6% 2.508 (2.411–2.609)
Non-affective psychosis 621, 0.8% 212, 0.2% 3.382 (2.883–3.967)
Adjustment disorder 224, 0.3% 244, 0.3% 1.281 (1.063–1.546)
Total 76,356, 100% 96,356, 100%
1796
varied only minimally between significant diagnostic groups,
but nonetheless the highest association was for anti-social
personality disorder and non-affective psychotic diagnosis
(Table 1).
3.3. Drug use
Only a minority of subjects were screened for drug abuse.
The current analyses left us with 12,785 (16.6%) cases with
borderline intellectual functioning and 10,528 (10.9%) con-
trols with average IQ who were screened for drug abuse.
Logistic regression controlling for SES demonstrated that
individuals with borderline intellectual functioning were
significantly more likely to use drugs (OR =1.2, 95%
CI= 1.07–1.35).
4. Discussion
In this study a unique, population-based database was used,
which included a detailed assessment of all Israeli 16–17
years old male adolescents, in order to examine the
relationship between borderline intellectual functioning
and psychosocial variables. We found that compared to
those with average intellectual functioning, young men with
borderline intellectual functioning had increased rates of
poor social functioning, psychiatric diagnoses, and drug
abuse with the higher rates of poor social functioning
present even in those subjects without any psychiatric
diagnosis.
These data are supported by findings of other investiga-
tors using different designs and different populations
(Rajput et al., 2011). Particularly, the results of Hassiotis
et al. (2008) are remarkably similar to the results of the
current study, as their findings show that people with
borderline intellectual functioning suffer from a social
disadvantage, increased rates of neurotic disorders, more
depressive episodes, phobias, substance misuse and person-
ality disorders, as compared to their peers of normal
intelligence.
The finding that individuals with borderline intellectual
functioning were more than twice as likely to have any
psychiatric diagnosis as those with average IQ is in line with
previous literature which indicates that cognitive impair-
ment appears to be associated with the entire spectrum of
psychiatric disorders (Weiser et al., 2004; David et al.,
2008). The finding that individuals with borderline intellec-
tual functioning were more likely to have poor social
functioning, psychiatric disorders and drug use might indi-
cate that low IQ is at least in part a risk factor for generally
poor functional outcome.
According to the Flynn effect (Flynn, 1987) almost all
cultures gained 20 points in their IQ scores since 1930 to the
present day. Flynn (1987) indicated that this IQ gain is due
to an increase in the fluid IQ component of the IQ test, a
component that measures mainly abstraction abilities and
on the spot problem solving. In a world that demands these
abilities in everyday life, people with borderline intellectual
functioning might experience many difficulties and adjust-
ment problems.
Our data combined with previous data by other groups
emphasize the vulnerability of individuals with borderline
K. Gigi et al.
intellectual functioning. Taking into account the high pre-
valence of this group in the population (approximately
13.5%) and their poor outcome, this issue should be
considered as a public health issue. This attitude is
reflected in a recently published paper (Salvador-Carulla
et al., 2013) stating that borderline intellectual functioning
is a “health meta-condition that requires specific public
health, education and legal attention”.
Our data indicate that 30% of the borderline intellectual
functioning subjects from our sample suffered from poor
social functioning at age 17. This sub-group should be
considered at-risk, and public health strategies should be
developed to mitigate this vulnerability.
Clinicians and psychiatrists might take these factors into
consideration when treating individuals with borderline
intellectual functioning in a manner similar to the approach
to treating individuals with somatic risk factors such as
obesity and hypertension which are associated with poor
medical outcome (WHO, 2013a, 2013b).
4.1. Limitations
The interpretation of the findings reported here should be
viewed in light of two main limitations:
First, the results are not based on the entire population
of adolescents, but only on 17 years old males.
Second, the results regarding the drug use rates are
based on a subsample of male adolescents with poor social
adjustment or other behavioral problems, both of whom are
more prone to drug use (Sussman et al., 2000) and at
increased risk of later schizophrenia diagnosis (Davidson
et al., 1999; Weiser et al., 2001). However this is by far the
largest group of borderline intellectual functioning subjects
that has been studied.
In summary, borderline intellectual functioning is asso-
ciated with poor psycho-social functioning and increased
risk for psychopathology. Clinicians should be aware of the
psychopathological vulnerability and poor social outcome of
this group.
Role of funding source
This research received no specific grant from any funding agency,
commercial or not-for-profit sectors.
Contributors
Karny Gigi performed the statistical analysis and drafted the
manuscript. Nomi Werbeloff and Shira Goldenberg commented on
the statistical analysis and on the manuscript. Shirly Portuguese and
Eyal Fruchter were responsible for the data collection. Abraham
Reichenberg: advised on the statistical analyses. Mark Weiser
conceived and designed the study, supervised the statistical ana-
lyses and writing.
All authors contributed to and have approved the final
manuscript.
Conflict of interest
All authors declare that they have no conflicts of interest.
Borderline intellectual functioning
Acknowledgment
None.
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