Psycho Pathological Considerations

‫ مجدي‬/ ‫مع التحية لدكتور‬ Adolescents With Borderline Intellectual Functioning: Psychopathological Risk ABSTRACT This paper presents a qualitative analysis of cognitive and emotional functioning in intellectually borderline adolescents (IQ ranging from 71 to 84) and the consequences for personality and social development. Psychopathological risk, particularly in terms of mood disorders, conduct disorders, and intellectual deterioration, is analyzed, with the distinction made between "excited" and "inhibited" forms. Conceptualizations intellectually borderline adolescents have of their own mental functioning are described in light of the notion of cognitive self--the ability to understand and control internal and external reality. The implications for psychotherapy and rehabilitation are discussed. Learning disability is common in most of these children, appearing at the beginning of school attendance. Some children with early-onset hyperactivity and excitability evidence oscillating mood and lability of attention, which are expressed mostly in the scholastic context, adding oppositional behavior to the learning disability. These clinical manifestations can be categorized as "excited." In children with early-onset apathy, the experience of scholastic failure becomes the traumatic core around which their personality is built; they are oriented toward a feeling of failure, precarious selfesteem, and relational withdrawal. This is the "inhibited" form. Adolescence can accentuate the clinical features of the previous phases, either by further reducing emotional and behavioral control or by increasing feelings of incompetence and failure as well as the tendency toward relational withdrawal. In the excited form, adolescents can manifest adaptation disorders (they are particularly sensitive to external stress, even when not significant), conduct disorders or, in the most severe cases, antisocial or borderline personality disorders. Motor hyperactivity tends to decrease, while the weakness of the ego functions is more evident. This is expressed as poor tolerance for anxiety and frustration, difficulty in impulse control, and inability to defer gratification. These adolescents generally resort to acting out, while depressive feelings or neurotic manifestations (phobic or obsessive) are less common. Sometimes underlying a megalomaniacal appearance are feelings of loneliness and abandonment. Relational inconsistency is frequent. Tyrannical and possessive relations hips and clamorous refusals when faced with abandonment or simple frustrations are common with these adolescents. Conceptualization of time, in terms of continuity, sequence, and stability, is precarious to the point of dyschrony (Gibello, 1984). Inhibited adolescents tend toward relational withdrawal, apathy, and lack of motivation. Depressive feelings are more frequent, centering on the problem of weak cognitive functioning; namely, their "cognitive self" (Masi, Marcheschi, & Pfanner,

1996). A weak cognitive self is not a depressive condition in the strict sense, but can be the first step toward true depression, especially if life events or constitutional predisposition lead in this direction (Fine, Haley, Gilbert, & Forth, 1993). A learning disability can be a source of chronic distress for a child and even more so for an adolescent. Incidence of depressive disorders in those with a learning disability is at least two to three times higher than in the normal population (WrightStrawderman & Watson, 1992; Huntington & Bender, 1993). Weisz, Sweeney, Proffit, and Carr (1993) noted that perceptions of scholastic competence and the possibility of influencing this competence accounted for 35% of the variance in scores on a depression assessment scale (e.g., the Children's Depression Inventory; Kovacs, 1981). Further, depression is often accompanied by suicidal ideas or attempts (Peck, 1985; Pfeffer, 1986). Peck (1985) found that 50% of the adolescents in the suicide cases he investigated had a learning disability before they were 15 years of age. Therefore, recognizing the warning signs, especially in the scholastic environment, is particularly important. A form of cognitive indifference prevails among the excited adolescents: thought is slowed, associations strained, and fantasy life poor. There are few hopes, desires, or fears--just "objects and facts." These adolescents seem unable to think in anything but concrete terms. A significant relationship or a memory is considered real to them only because it is embodied in a concrete object (e.g., a necklace). Cognitive functioning in inhibited adolescents is characterized less by concreteness of thought and more by the presence of "empty thought." Sometimes there is pseudoadaptive overinvestment, which is an attempt to disguise cognitive failure. Learning can be obsessive and rigid, sometimes involving content "far in space and time" (e.g., exotic birds, stars, prehistoric animals, ancient Egyptians). It is more frequent in cognitively borderline adolescents who live in more cultured and demanding families. This "false cognitive self" provides a way of denying the reality of inadequate intellectual functioning. Family interactions can influence, and be influenced by, the excited and inhibited forms. As an example, a cognitive deficit can modify the way parents conceptualize their adolescent son: they may introduce into these representations a regressive element ("he can't do it"), which is more frequent for the inhibited adolescent, or a transgressive element ("he could do it, but he doesn't want to"), which is more frequent for the excited adolescent. The adolescent may adhere to such representations or oppose them in a superficial way, either of which creates an obstacle to the individuation process. When a regressive element is present, it is not rare to find child and parent uniting around homework. This often powerful "scholastic symbiosis" can be an obstacle to individuation, assuring an unending latency period. With the transgressive element, the adolescent manifests deviant and oppositional behavior. Problems are not faced and there is a tendency toward acting out.

CLINICAL CONSIDERATIONS

In adolescence there is a close relationship between emotional development and cognitive development (Masi, Poli, & Marcheschi, 1994). Just as emotional disorders can interfere with intellectual functioning, cognitive difficulties can be a risk factor in personality development. Cognitive dysfunction can interfere with conceptualizations of reality, reduce the ability of adolescents to deal successfully with emotional tensions as well as pubertal transformations, and disrupt relations between the individual and the outside world. These developmental risks are also present in persons who are intellectually borderline according to the DSM-IV (American Psychiatric Association, 1994) and the ICD-10 (World Health Organization, 1992)-those having an IQ ranging from 71 to 84. They are more than one standard deviation below the average, but do not fall into the diagnostic category of mental retardation (IQ less than 70), which is more than two standard deviations below the average. The DSM-IV includes poor intellectual functioning among "additional conditions that may be a focus of clinical attention." A qualitative analysis of cognitive development in Piagetian terms reveals a delay for intellectually borderline adolescents: concrete operational thought is generally achieved after age 10-12; formal operational thought is seldom reached. They also display rigid cognitive functioning (e.g., the inability to modify conceptualizations and difficulty in considering problems from another point of view). Further, the ability to plan, analyze, and undertake tasks is often limited. There is poor awareness of their own thought processes, which therefore are not used to the fullest. Their approach to learning is passive, with a tendency to resort to memorizing, which becomes insufficient when the verbal load is excessive. Impairment is greater in the more original and creative areas of mental functioning, such as logical reasoning and metacognitive abilities (Masi, Marcheschi, & Pfanner, 1996). There is often low selfesteem, characterized by the conceptualization of a cognitively incompetent self: the youth does no t feel confident about the possibility of control over internal and external realities and over his or her own future. The difficulties tend to increase as scholastic demands become more complex. This tendency is not necessarily observed in the extrascholastic cognitive competencies that influence social interaction or job performance; in fact, many daily activities, including numerous work tasks, do not require logico-formal thought and can be carried out by the cognitively borderline. Consequently, when schooling ends, adaptation seems to depend less on cognitive factors and more on personality organization, relational attitudes, ability to control emotions and impulses, and self-confidence. For this reason, psychopathological assessment becomes particularly important. The psychopathological risk of the mentally retarded has been pointed out--their cognitive deficit is a significant indicator of vulnerability (Bregman, 1991; Masi, Marcheschi, & Pfanner, 1996). However, less attention has been paid to those with borderline intellect. Cognitively borderline persons are not equipped with the mental abilities of those with normal intelligence, which ensure better potential for analyzing and working out internal and external conflicts. Nor do they have the reduced mental complexity of the retarded, which permits a degree of emotional balance. Thus, intellectually borderline individuals show instability, especially when faced with external pressures (e.g., separations, frustrations) or perturbing internal events, such as adolescent transformations.

Another risk is the progressive deterioration of intellectual functioning. Cognitively borderline children and adolescents are particularly sensitive (much more than normal-IQ subjects) to the quality of their life experiences; a deprived, frustrating, or poorly stimulating environment can further reduce their intellectual efficiency. Borderline intellectual functioning in itself is not a pathological condition, but it can become one if further intellectual deterioration is activated by any number of disorders or unfavorable events. It is generally possible to detect a mild and aspecific slowing in early psychomotor and linguistic development. Some of these children manifest an early tendency toward apathy, for which they are described as "children that are even too good," even without significant relational distortions. Others show early irritability, motor hyperactivity, and impulsiveness, which may already be evident when they enter kindergarten.

PSYCHOPATHOLOGICAL CONSIDERATIONS A significant aspect of borderline intelligence is the conceptualization that children, but above all adolescents, have of their own mental functioning--the cognitive self. The perception they have of their ability to comprehend, integrate, and control internal and external experiences has repercussions for psychopathology. Normally, the cognitive self provides defense mechanisms (e.g., rationalization, intellectualization) that are especially important in transitional stages, such as adolescence. Borderline intelligence, however, can undermine the stability of the cognitive self, promoting negative interpretations of mental functioning. This can be the source of some of the most frequent psychopathological manifestations in these adolescents. First, a weak cognitive self may lower self-esteem and increase feelings of inadequacy (i.e., personal helplessness) in relation to peers (Weisz, Sweeney, Proffit, & Carr, 1993). Adolescents with a weak cognitive self often feel they have a poor hold on reality, and the future seems beyond their control. Relational initiative is poor; in short, their approach is passive. This predisposes them even more to the development of a depressive disorder. Second, the perception of cognitive incompetence can involve a fear of not being able to control impulses--sexual and, above all, aggressive, which are typical of the adolescent stage of development. These adolescents describe being compulsively driven by an uncontrollable interior force. This psychopathological condition may evolve into conduct disorders. Third, adolescents at risk for depression as well as for conduct disorders take no pleasure in mental functioning--that is, in reflecting on the nature of their own thought processes. Self-knowledge of their deficit is painful. The weakness of the cognitive self, at times relatively circumscribed, can also become pervasive; the cognitive self seemingly becomes dominated by its own self-representation. This can lead to acute anxiety disorders, dramatic scholastic interruptions, social withdrawal, acting out (e.g., running away from home), and even suicide attempts.

Representations of the cognitive self, lying between the covert level of emotions and the overt level of behavior, constitute a framework for understanding reality and for organizing behavior. Two types of theories are helpful in describing the weakness of the cognitive self in persons with mild intellectual deficits: beliefs about one's own ability to think--theories of intelligence (Dweck & Leggett, 1988), and beliefs about the factors that produce success or failure--attributional theories (Weiner, 1985). Dweck and Leggett (1988) identified two ways of understanding intelligence: "incremental," according to which intelligence can change and develop and, above all, be controlled by the individual, and "entity," according to which intelligence is fixed and unchanging and, above all, beyond personal control. In previous research (Masi, Pfanner, Marcheschi, & Poli, in press), it was found that subjects with learning difficulties had a significantly higher frequency of static representations of intelligence than did normal subjects. They perceived their cognitive and learning abilities as unchangeable, and they underestimated the role of cognitive effort in the learning process, resulting in a reduction of more effective behavior and attitudes. Persons with static conceptions of intelligence tend to have "performance goals" with respect to learning tasks; that is, they prefer obtaining gratification or, more often, avoiding frustration, rather than increasing their ability. They try to maintain their sense of self-esteem by avoiding situations in which their inadequacy can emerge. Learning is perceived as threatening and anxiety producing--a situation in which their abilities are tested and are almost always found wanting. Other characteristics are feelings of helplessness, performance deterioration at the first sign of difficulty, and pessimism about success. These can be considered expressions of a weak cognitive self. Attributional theories analyze the ways an individual identifies the causal factors of events (Weiner, 1985). Those with learning disorders tend to attribute failure to internal factors (poor ability, low intelligence), while they attribute success to external factors beyond their control (luck, help from others). If they do attribute success to internal factors, they do so in terms of the excessive effort used to reach the performance levels of their peers (Jacobsen, Lowery, & Du-Cette, 1986). Attributional theory also has prognostic significance: individuals who attribute failure to factors they can control (for example, not trying very hard) show, over time, more progress (Kistuer, Osborne, & LaVerrier, 1988). Gaining cognitive skills does not guarantee that the adolescent will use them. Motivational factors are closely associated with a reinvestment in the cognitive self, which may require different interventions depending on the degree of impairment. In milder cases it is sufficient to modify the rigidity of the representations of the cognitive self (i.e., in light of intelligence and attributional theories). This can be accomplished in discussion groups. This type of intervention can make the rehabilitation more effective, in terms of both maintenance (retaining acquisitions over time) and generalization (extending these acquisitions to different contexts), while at the same time preventing emotional and behavioral disorders. When the weakness of the cognitive self is more pronounced, it is useful to add supportive psychotherapy to the functional rehabilitation, with a separate therapist and in a parallel setting. Supportive therapy can aim more directly at bolstering the

adolescent's self-image, relations with significant others, and understanding of, and control over, internal and external experiences. In more severe cases, early and intense narcissistic failings make rehabilitation extremely difficult. However, psychodynamic psychotherapy, focusing on the intrinsic anomalies of the adolescent's personality, can impede progression toward chronic acting out or withering of psychic life. The purpose of psychodynamic intervention is to establish a relationship among memories, feelings, and events (such as experiences of abandonment, deprivation, and physical or sexual abuse). It should have priority over other rehabilitative strategies. Common to all these forms of intervention is the need to maintain control over psychotherapeutic (countertransferential) dynamics, which are particularly complex in any interaction with an adolescent suffering from a cognitive deficit (Gibello, 1984; Masi, Marcheschi, & Pfanner, 1996). Undoubtedly, dealing with an adolescent with borderline intellectual functioning sometimes activates aggressive dynamics, which may result in a reduction in therapeutic depth in favor of behavioral intervention. Nevertheless, a therapeutic relationship that maintains its focus on the particular outlook and needs of the intellectually borderline adolescent will improve the chances for a favorable outcome. Mara Marcheschi, M.D., and Pietro Pfanner, M.D., Institute of Developmental Neurology, Psychiatry, and Educational Psychology, University of Pisa--Stella Mans Scientific Institute, Italy. Reprint requests to Gabriele Masi, M.D., Institute of Developmental Neurology, Psychiatry, and Educational Psychology, University of Pisa--Stella Maris Scientific Institute, Via dei Giacinti 2, 56018 Calambrone (Pisa), Italy