Child Psychiatry: Additional Conditions That May Be a Focus of Clinical Attention

BORDERLINE INTELLECTUAL FUNCTIONING

Intellectual functioning of a child or adolescent is influenced by multiple factors, including birth history of full-term gestation, neonatal head circumference, learning, nutritional status, and brain development after birth. Brain parameters, parental head circumference, and prenatal nutrition are most correlated with the head circumference of the newborn. In a sample of Chilean school-age children, those born with small head circumference of at least two standard deviations below the mean (microcephalic) were most likely to present with lower overall brain volume, compromised intellectual and scholastic functions, and poor nutrition. Although intellectual quotients (IQs) are generally believed to be stable over time, in some cases, a single measurement of intellectual functioning does not accurately predict intellectual function in all areas over the long term. For example, a follow-up study conducted to investigate the stability of IQ measurement in a group of dyslexic adolescents and young adults who were tested at age 12 years and retested after a mean interval of 6.5 years found the following differences over time: Compared with first IQ tests, for the teens and young adults, the retests showed a significant relative decrease in verbal IQ (VIQ), which was interpreted as either poor reliability of the test or a loss of ability based on diminished experience with reading and writing compared with same-age peers over time. Performance IQ (PIQ), however, was found to be significantly increased, leading to the hypothesis that a compensatory process had been developed by these children with dyslexia, such as a more visual or creative way to process information, leading to greater success on performance test items. The conclusion was that a single IQ test in childhood may not be a fully accurate predictor of later abilities and that potential interventions to help children with disabilities such as dyslexia keep up academically with peers may have implications for final IQ and intellectual functioning.

Borderline intellectual functioning, according to the text revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), is a category that can be used when the focus of clinical attention is on a child or adolescent with IQ in the 71 to 84 range. The intellectual functioning of children plays a major role in their adjustment to school, social relationships, and family function. Children who cannot quite understand class work and may also be slow in understanding rules of games and the social rules of their peer group are often bitterly rejected. Some children with borderline intellectual functioning can mingle socially better than they can keep up academically in class. In these cases, the strengths of these children may be peer relationships, especially if they excel at sports, but eventually, their academic struggles will take a toll on self-esteem if they are not appropriately remediated.

Etiology

Genetic factors are increasingly being found to play a role in intellectual deficits. Environmental deprivation and infectious and toxic exposures can also contribute to cognitive impairment. Twin and adoption studies support the hypothesis that many genes contribute to the development of a given IQ. Specific infectious processes (e.g., congenital rubella), prenatal exposures (e.g., fetal alcohol syndrome), and specific chromosomal abnormalities (e.g., fragile X syndrome) result in mental retardation.

Diagnosis

The DSM-IV-TR contains the following statement about borderline intellectual functioning:

This category can be used when the focus of clinical attention is associated with borderline intellectual functioning, that is, an IQ in the 71 to 84 range. Differential diagnosis between Borderline Intellectual Functioning and Mental Retardation (an IQ of 70 or below) is especially difficult when the coexistence of certain mental disorders (e.g., Schizophrenia) is involved. Coding note: This is categorized on a V Code.

Treatment

The goals of treatment are to maximize educational and vocational placements so that individuals can develop the most optimal practical adaptive skills, social skills, and self-esteem. The goal is to improve the match between the person’s capabilities and lifestyle. After the underlying problem becomes known to the therapist, psychiatric treatment can be useful. Many persons with borderline intellectual functioning can function at a superior level in some areas while being markedly deficient in others.
By directing such persons to appropriate areas of endeavor, by pointing out socially acceptable behavior, and by teaching them living skills, the therapist can help improve their self-esteem.

ACADEMIC PROBLEM

The DSM-IV-TR refers to an academic problem as a problem that is not caused by a mental disorder or, if caused by a mental disorder, is sufficiently severe to warrant clinical attention. This diagnostic category is used when a child or adolescent is having significant academic difficulties that are not deemed to be caused by a specific learning disorder or communication disorder or directly related to a psychiatric disorder. Nevertheless, intervention is necessary because the child’s achievement in school is significantly impaired. A child or adolescent of normal intelligence and who is free of a learning disorder or a communication disorder but is failing in school or doing poorly falls into this category.

Etiology

Many psychological factors contribute to a child’s confidence, competence, and academic success. In the absence of a specific learning disorder to account for the academic difficulty or primary psychiatric disorder responsible for the academic compromise, subclinical states of anxiety or depression or peer and family stressors such as divorce, marital discord, abuse, or mental illness in a family member may interrupt academic production. Children who are troubled by social isolation, identity issues, preoccupation with sexuality, or extreme shyness may withdraw from full participation in academic activities. Academic problems may be the result of a confluence of multiple contributing factors and may occur in adolescents who were previously high academic achievers. School is the main social and educational venue for children and adolescents. Success and acceptance in the school setting depend on children’s physical, cognitive, social, and emotional adjustment. Children’s general coping mechanisms in many developmental tasks usually are reflected in their academic and social success in school. Boys and girls must cope with the process of separation from parents, adjustment to new environments, adaptation to social contacts, competition, assertion, intimacy, and exposure to unfamiliar attitudes. A corresponding relation often exists between school performance and how well these tasks are mastered.

Anxiety can play a major role in interfering with children’s academic performances. Anxiety can hamper their abilities to perform well on tests, to speak in public, and to ask questions when they do not understand something. Some children are so concerned about the way in which others view them that they cannot attend to their academic tasks. For some children, conflicts about success and fears of the consequences imagined to accompany the attainment of success can hamper academic success. Sigmund Freud described persons with such conflicts as “those wrecked by success.” For example, an adolescent girl may be unable to succeed in school because she fears social rejection, the loss of perceived femininity, or both, and she may perceive success as being involved with aggression and competition with boys.

Depressed children also may withdraw from academic pursuits; they require specific interventions to improve their academic performances and to treat their depression. Children who do not have major depressive disorder but who are consumed by family problems, such as financial troubles, marital discord between their parents, and mental illness in family members, may be distracted and unable to attend to academic tasks. Children who receive mixed messages from their parents about accepting criticism and redirection from their teachers can become confused and unable to perform well in school. The loss of the parents as the primary and predominant teachers in a child’s life can result in identity conflicts for some children. Some students lack a stable sense of self and cannot identify goals for themselves, a situation that leads to a sense of boredom or futility.

Cultural and economic background can play a role in how well accepted a child feels in school and can affect the child’s academic achievement. Familial socioeconomic level, parental education, race, religion, and family functioning can influence a child’s sense of fitting in and can affect preparation to meet school demands.

Schools, teachers, and clinicians can share insights about how to foster productive and cooperative environments for all students in a classroom. Teachers’ expectations about their students’ performance influence these performances. Teachers serve as agents whose varying expectations can shape the differential development of students’ skills and abilities. Such conditioning early in school, especially when negative, can disturb academic performance. A teacher’s affective response to a child, therefore, can prompt the appearance of an academic problem. Most important is a teacher’s humane approach to students at all levels of education, including medical school.

Diagnosis

The DSM-IV-TR contains the following statement about the category of academic problem:

This category can be used when the focus of clinical attention is an academic problem that is not due to a mental disorder or, if due to a mental disorder, is sufficiently severe to warrant independent clinical attention. An example is a pattern of failing grades or of significant underachievement in a person with adequate intellectual capacity in the absence of a learning or a communication disorder or any other mental disorder that would account for the problem.

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