Recommendations for

caring for people with

Borderline Intellectual
Functioning

26 May 2017
[Link]/funcionament_intel_lectual_limit
Recommendations for
caring for people with
Borderline Intellectual
Functioning
Contents
Chapter I. Presentation .................................................................................................... 5

Chapter II. Introduction ..................................................................................................... 6

Chapter III. Objectives and organisation ............................................................................ 9

Chapter IV. Improvement and early detection and confirmation of the BIF
diagnosis ....................................................................................................... 17

Section 1. Detection process and alarm signals ............................................................. 19

Section 2. Diagnostic process ........................................................................................ 23

Section 3. Legal and forensic medicine .......................................................................... 27

Section 4. Resources involved in detection and diagnostic processes ........................... 30

Section 5. Screening and identification .......................................................................... 32

Chapter V. Individualised intervention plan ..................................................................... 39

Section 1. Children and adolescents diagnosed with BIF or at risk for BIF .................... 40

Section 2. Adults with BIF and mental illness ................................................................. 46

Chapter VI. Employability ................................................................................................. 51

Section 1. Intervention process for improving employability ........................................... 54

Chapter VII. Interdepartmental and interprofessional coordination .................................... 57

Section 1. Interservice coordination ............................................................................... 58

Section 2. Recommendations on information and documentation .................................. 59

Section 3. Care and support for families ........................................................................ 59

Section 4. Training for professionals ............................................................................. 60

Section 5. Existing resources ......................................................................................... 61

Chapter VIII. Glossary ........................................................................................................ 65

Chapter IX. Bibliography .................................................................................................. 75

4
I. Presentation
Borderline intellectual functioning (BIF) is a condition that affects a considerable proportion of
the population, impacting on people's quality of life and on their social and labour
employment inclusion. Despite its social impact and frequency, BIF is still not sufficiently
recognised by health, social, education, employment and legal systems at an international
level.

Many years ago, an initiative was started in Catalonia by people working in the Government
who created the Nabiu Catalan Association in order to ensure the maximum normalisation of
this group in social and work contexts. As a result of this, a good model of employment
inclusion for some people was achieved within the public administration.

Moreover, in 2009 the Ministry of Health supported a research project considered to be

pioneering at an international level, and the Consensus Manual on Borderline Intellectual
Functioning was drawn up, with the coordination of leading national and international experts
such as Dr Luis Salvador Carulla, Dr Ramon Novell and Dr José Garcia Ibáñez.

The Catalan Government is well aware that caring for people with BIF requires a cross-
cutting and inter-sectoral vision, involving health, education, social, employment and legal
services. For this reason, a BIF Consensus Group was created in 2014, including
professionals from different fields specialised in care provision for this group. The aim of the
consensus group has been to draw up recommendations to improve the early detection and
diagnosis of BIF, to define an individualised intervention plan, to improve social integration
and to ensure interdepartmental and interdisciplinary coordination when caring for this group.

Today, Catalonia has a document providing recommendations for the comprehensive care of
people with BIF which is pioneering at an international level. This has been made possible
thanks to the collaboration of the experts in this field and the work they have carried out over
the years for the Nabiu Catalan Association.

5
II. Introduction
Borderline Intellectual Functioning (BIF) is a condition that affects at least 3% of the
population and that compromises to reach adequate levels of functioning (for example, a
basic level of school education or access to the job market).

Studies exploring the international scientific evidence in this field are scarce and the results
are highly variable. From the 12.3% of BIF population identified in the general British
population (Hassiotis et al., 2008) to the 3% level identified in the Spanish population
(Salvador-Carulla et al, 2011). In the context of the prison population, this prevalence is
shown to be even more variable in the different studies available; from 5.7% (Murphy,
Harnett& Holland, 1995), 11% (Herrington, 2009), 23.6% (Hayes, S.;Shackell, P.;Mottram,
P.; Lancaster, 2007) and 32.1% (Porta, Martínez-Gómez & Pineda, 2003). The factors
offered to explain these percentual variations are the use of different population samples, the
lack of standardisation of the criteria used to categorise BIF, and the difficulty in identifying
people with it.

Taking into account the situation, a group of experts drew up a declaration and framework
document to provide a response to the challenges involved in caring for people with BIF. This
document has come to be known as the Consensus Manual on Borderline Intellectual
Functioning in which the group made 10 recommendations:

1. BIF is a meta-health condition that requires specific social, health, educational and legal
attention. It is characterised by diverse cognitive dysfunctions which are associated with
an intelligence quotient of between 71 and 85, and which result in deficits in the person
both in terms of the restriction on the activities they can carry out and in terms of their
social participation.

2. The childhood population with BIF is more vulnerable than the general population and
therefore early detection is needed, as well as psychopathological assessment and an
assessment of learning potential in these cases.

3. People with BIF need support to facilitate their school, employment and social adaptation
and, in some cases, to also care for their specific health needs.

4. With regard to children and young people, it is expected that the concept of BIF will need
to be defined with criteria that will help delimit a group of people who are unable to be
schooled like most children of the same age and social environment, even though they
do not have an intellectual disability.

5. The BIF concept presents a high level of variability and cultural baggage.

6
6. The difficulties facing the BIF population when accessing legal and administrative
processes lead to a feeling of helplessness that must be addressed.

7. The early detection, assessment and care of people with BIF must be explicitly included
in the health, social, school, employment and legal fields, in order to develop a society
based on the principles of justice, equality and diversity.

8. More research must be promoted on the different aspects of BIF from health, social,
educational, employment and legal perspectives.

9. Training on BIF should be improved for professionals in the different fields involved in
providing care services for this group.

10. Specific spaces for interdepartmental coordination in different geographical areas should
be promoted, as well as spaces for sharing knowledge between professionals from
different sectors (health, education, work, social, and legal).

Based on these recommendations, the Catalan Government has set up a BIF Consensus
Group, made up of professionals from the different fields, representatives of the different
governmental departments involved, and by the Nabiu Catalan Association, in order to draw
up a document providing recommendations on the comprehensive care of people with BIF.

BIF and mental illness

BIF is a heterogeneous group of syndromes, disorders or specific neurodevelopmental
illnesses with potentially extreme variations in relation to normal functioning, which share one
common characteristic: the secondary functional limitation of intellectual capacity.

In the latest diagnostic classifications (DSM-5 and CIM-10), BIF is still not classified as a
clinical diagnostic category within the area of disabilities. It is classified, however, as a
secondary category. Nevertheless, its coding is recommended in the diagnostic codes
usually used in the health system (V62.89, according to CIM 9 and 10, and R41.83 according
to DSM-5).

Considering the high level of mental illness in people with BIF, we feel compelled to highlight
this dual condition.

A high degree of variability exists in the scientific literature when discussing mental illness in
BIF. Having said that, research in this area is scarce and samples very rarely concentrate on
this population in isolation; it being common to find studies in which BIF patients are selected
alongside patients with minor or moderate levels of intellectual disability. In the past, the lack
of bibliography on psychopathology in BIF has led to this demographic being compared with

7
patients with neurological disorders (Seidel, Chadwick & Rutter, 1975)

Usually, it is believed that at least 25% of subjects with BIF have psychiatric problems
associated with cognitive deficits (Koller, 1983; Rutter, 1970; Gostasson, 1985).

Hassiotis (1999, 2008) carried out a study with a sample of 8,450 adults extracted from the
‘British National Survey of Psychiatry Morbidity’ database, in order to assess BIF prevalence
in the population and the frequency of mental illness in this group. The sample studied shows
12.3% of people with BIF. Within this group, the prevalence of phobias, depression, neurotic
disorders, personality disorders and substance abuse disorders (alcohol, cannabis and other
drugs) was significantly higher than the group with normal levels of intelligence.

As people who are on the borderline between those with normal intelligence and those with
intellectual disabilities, they will veer towards one side or the other of the border depending
on the circumstances produced in their lives, their ability to overcome unfavourable
situations, and the support they receive.

It is well known that some individuals with BIF function are completely independently,
needing support only occasionally (Baxter et al., 2006), and functioning in a very similar way
to the general population. However, there is a group of people with BIF, in the lowest part of
this bracket, that overlaps with intellectual disability.

If the deviation occurs on the side of intellectual disability, the cognitive and functional deficits
involved in managing daily life without appropriate support, the emotional repercussions of
situations of failure, and the experience of feeling different from others, are aspects that can
impact on their mental health and behaviour.

Furthermore, it should be noted that the lack of recognition and attention given from the
standard mental health network to the inherent cognitive difficulties experienced—especially
executive functions—and to the atypical way in which mental disorders are often manifested,
as well as to the lack of training of professionals, can mean that their special needs are not
identified and, consequently, that they do not receive the support needed to live as normal a
life as possible.

8
III. Objectives and organisation
This document brings together the consensus on criteria related to actions, measures and
support for the comprehensive care of people with BIF, targeted mainly at professionals in
the health (general health and mental health), education, social, employment and legal
spheres.

It also includes proposals and recommendations regarding organisational aspects, training,

new programmes and other aspects that are considered important, and on which further
work needs to be carried out to establish definitions, plans and implementation strategies.

This process, which covers everything from the detection of alarm signals and diagnosis to
the elaboration of a personal intervention plan for people with BIF, including proposals to
facilitate their employability, implies a joint effort by all professionals working in these fields.

The main objective of this document is to offer recommendations to:

1. Improve early detection, with the aim being to try to do this from early ages within the
context of the education or health system, with professionals who are in direct contact
with children, whether in general health contexts (paediatrics) or in specialist centres or
preschool formal educational contexts (0-6 years). A second level of detection would be
during primary and secondary education, since many students with BIF can also be part
of the group of students at risk of school failure if they do not receive educational
attention adapted to their needs.

2. Confirm the BIF diagnosis, being fully aware that at this moment in time it is not
considered a diagnosis of mental health1.

3. Define an individualised intervention plan at all life stages of the person with BIF:
 Social and health monitoring.
 Professionals and scope of intervention.
 During childhood and youth: specific details in the Individualised support plans (IP) of
students with BIF of the measures and additional or intensive support to be applied to

1
If we look exclusively at the normal distribution of IQ, the population group with an IQ of between 71 and 85 would represent
13.6% of the total (EDAD 2008). The majority do not present any difficulties in their daily life. As indicated in the Manual, from
a conservative perspective, the BIF Consensus Group has estimated that the population within this IQ range could be around
3% of the population. If we consider from this group those with a clear need for socio-health care, the ‘baseline’ would be
around 1%. These would be people who have been subjected to demands that have exceeded their capacities from a very
early age (due to ignorance within their environment of the problem) and have thus developed disorders as a result of this.
Sometimes these disorders can be serious, as shown when people with BIF are admitted to HUSID and residential centres for
people with intellectual disabilities or mental disorders. It is because of this that the early detection and recognition of their
situation is important in the context of education.

9
 help them achieve the objectives established at each stage of education.
 During adulthood: specific details in the Individualised support plans (IP) of adults
with BIF of the measures and additional or intensive support to be applied to help
them achieve (personal, social and labour) objectives in their lives, especially in
relation to the difficulties they have regulating emotions and behaviour that can lead
to mental disorders. Within the labour context, this group of people need to be
considered as a particularly vulnerable group whose integration should be promoted.
 Support and potential aid for families.

4. Ensure interdepartmental and interprofessional coordination when providing care for

people with BIF and also in highly complex situations, providing spaces for the
coordination between the professionals involved in such cases.

BIF Consensus Group

In order to produce this document, the Government has set up the BIF Consensus Group,
made up of professionals from the Catalan Government Administration who work in services
related to the field, and external professionals who are experts in the subject. The BIF
Consensus Group has been organised in the following way to facilitate full attainment of the
objectives set.

10
The different agents involved in this system of the BIF Consensus Group are:

 The Catalan Government, acting as the driving force behind the project.
 Nabiu Catalan Association, responsible for promoting the need to develop this document.
 BIF Working Group, working system set up to elaborate this document.

BIF Working Group

The BIF Working Group is made up of the Advisory Board, the Coordination Group and the
different working groups.

Advisory Board

The highest functional coordination board is responsible for approving the focus and scope of
the project and the final document. It is made up of the following people:

From the Catalan Government:

 Joan Vidal de Ciurana. Cabinet Secretary. Ministry of the Presidency.

 Elsa Artadi. Director General for Interdepartmental Coordination. Ministry of the
Presidency.
 Elvira Balcells. Sectorial Monitoring Analyst Ministry of the Presidency.
 Francesc Fransí. Head of Area of Health and Safety at Work and Social Policy. Ministry
of Governance, Public Administrations and Housing.
 Neus Jornet. Executive Secretary of the Catalan Board of Professional Training. Ministry
of Education.
 Carme Altes. Head of Care Services for Diversity and Inclusion. Ministry of Education.
 Cristina Molina. Director of the Mental Health and Addictions Master Plan. Ministry of
Health.
 Dr Jordi Medallo Muñiz. Director of the Institute of Legal Medicine and Forensic Sciences
of Catalonia. Ministry of Justice.
 Mònica Ribas. Assistant Director-General for the Care and Promotion of Personal
Autonomy. Ministry of Labour, Social Affairs and Families.
 Lluís Grande. Assistant Director-General for Analysis and Programming. Ministry of
Labour, Social Affairs and Families.
 Maria Antònia López Sala. Head of the Programmes for Diversity Service. Ministry of
Labour, Social Affairs and Families.

11
Professional experts:

 Dr Marina Romeo. Director of the Chair for the Labour Integration of People with
Disabilities. University of Barcelona.
 Fernando Barbancho. Lecturer in Labour and Workplace Safety Law, University of
Barcelona.
 Marcel·lí Medina. Labour insertion technical education teacher. Teaching Unit. HDA in
Nou Barris.
 Dr Francisco Aguilera. Medical Director of Sanatori Villablanca. Institut Pere Mata.
 Dr Ramon Novell. Head of Intellectual Disability Services. PH Martí i Julià. Institut
d'Assistència Sanitaria. (Institute of Health Care).
 Dr Montse Pàmias. President of the Catalan Society for Child and Adolescent
[Link] of Medical Sciences of Catalonia and the Balearic Islands.
 Dr Àurea Autet. Catalan Society of Child and Adolescent Psychiatry. Head of Child and
Adolescent Psychiatry Services, Fundació Althaia.
 Assumpta Soler Ferràs. Municipal Institute for People with Disabilities. Barcelona City
Council.

Coordination Group

It coordinates project operations to facilitate the work done by the working groups.

It is made up of:

 Elvira Balcells. Sectorial Monitoring Analyst Ministry of the Presidency.

 Francesc Fransí. Head of the Workplace Health and Safety and Social Policy Area,
Ministry of Governance, Public Administrations and Housing.
 Carme Altes. Head of Care Services for Diversity and Inclusion. Ministry of Education.
 Cristina Molina. Director of the Mental Health and Addictions Plan. Ministry of Health.
 Dr Jordi Medallo Muñiz. Director of the Institute of Legal Medicine and Forensic Sciences
of Catalonia. Ministry of Justice.
 Mònica Ribas. Assistant Director-General for the Care and Promotion of Personal
Autonomy. Ministry of Labour, Social Affairs and Families.
 Maria Antònia López Sala. Head of the Diversity Programme Service. Ministry of Labour,
Social Affairs and Families.

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Working Groups

In line with the objectives set, the following working groups have been set up: one group to
develop objectives 1 and 2, two groups for objective 3 (one to draw up the Individualised
intervention plan and another to work on labour integration aspects) and a final group for
objective 4.

1. Working group for the Improvement and early detection and confirmation of the
BIF diagnosis

Professionals responsible
 Carme Altes. Head of Care Services for Diversity and Inclusion. Ministry of Education.

Professionals
 Dr Jordi Medallo Muñiz. Director of the Institute of Legal Medicine and Forensic Sciences
of Catalonia. Ministry of Justice.
 Dr Claudina Vidal. Assistant Director of the Barcelona City and Hospitalet de Llobregat
Division Institute of Legal Medicine and Forensic Sciences of Catalonia. Ministry of
Justice.
 Mercedes Zayas. Psychologist at the Early Childhood Care and Development Centre
(ECCDC), Passeig de Sant Joan. Ministry of Labour, Social Affairs and Families.
 Dr Montse Pàmias. President of the Catalan Society for Child and Adolescent Psychiatry.
Academy of Medical Sciences of Catalonia and the Balearic Islands.
 Dr Montse Dolz. Advisor member of Master Plan of Mental Health and Addictions of the
Generalitat of Catalonia and Director of the Child and adolescent Mental Health
Department of the Paediatric Sant Joan de Deu Hospital in Barcelona”.

13
2. Working group on the Individualised intervention plan

Entity responsible
 Cristina Molina. Director of the Mental Health and Addictions Plan. Ministry of Health.

Professionals
 Núria Roig. Technical education teacher, Care Services for Diversity and Inclusion.
Ministry of Education.
 Dr Jordi Medallo Muñiz. Director of the Institute of Legal Medicine and Forensic Sciences
of Catalonia. Ministry of Justice.
 Elena Boira i Orantes. Head of Support Actions for Families. Directorate General for
Families. Ministry of Labour, Social Affairs and Families.
 Mercedes Zayas. Psychologist at the Early Childhood Care and Development Centre
(ECCDC), Passeig de Sant Joan. Ministry of Labour, Social Affairs and Families.
 Dr Montse Pàmias. President of the Catalan Society for Child Psychiatry.
 Rosa Nicolau Palou. Clinical psychologist. Child and Adolescent Psychiatry and Clinical
Psychology Services. Neuroscience Institute. Hospital Clinic in Barcelona.
 Francisco Aguilera. Medical director of Sanatori Villablanca. Institut Pere Mata.
 Dr Ramon Novell. Head of the Intellectual Disability Service. PH Martí i Julià. Institut
d'Assistència Sanitaria. (Institute of Health Care).

3. Working Group on Employment Integration

Entity responsible
 Maria Antònia López Sala. Head of the Diversity Programme Service. Ministry of Labour,
Social Affairs and Families.

Professionals
 Francesc Fransí. Head of the Workplace Health and Safety and Social Policy Area.
Ministry of Governance, Public Administrations and Housing.
 Mercè Escudero. Directorate General for Professional Training. Ministry of Education.
 Mercè Talavera Zamora. Interdepartmental Relations Directorate General for Youth.
Ministry of Labour, Social Affairs and Families.
 Glòria Gomez. Head of the Promotion of Diversity Section. Ministry of Labour, Social
Affairs and Families.
 Marcel·lí Medina. Labour insertion technical education teacher. Teaching Unit. HDA in
Nou Barris.
 Neus Palos. Labour Director Associació Catalana d’Integració i Desenvolupament Humà

14
 (ACIDH) (Catalan Association for Human Integration and Development).
 Dr Marina Romeo. Director of the Chair for the Labour Integration of People with
Disabilities. University of Barcelona.
 Fernando Barbancho, Lecturer in Labour and Workplace Safety Law, University of
Barcelona.

4. Working Group on Interdepartmental and Interprofessional Coordination

Entity responsible
 Mònica Ribas. Assistant Director-General for the Care and Promotion of Personal
Autonomy. Ministry of Labour, Social Affairs and Families.

Professionals
 Ariadna Corbera Arumí. Technician in the Care Services for Diversity and Inclusion.
Ministry of Education.
 Pere Bonet. President of the Advisory Board on Mental Health and Addictions. Ministry of
Health.
 Dr Jordi Medallo Muñiz. Director of the Institute of Legal Medicine and Forensic Sciences
of Catalonia. Ministry of Justice.
 Montserrat Herrador Algaba. Director of the Care Centre for People with Disabilities in
Paral·lel. Ministry of Labour, Social Affairs and Families.
 Maria Antònia López Sala. Head of the Diversity Programme Service. Ministry of Labour,
Social Affairs and Families.

15
16
IV. Improvement and early detection and
confirmation of the BIF diagnosis

17
The indications provided in this chapter aim to summarise the information given in the
Manual, specifying general guidelines aimed at professionals in the different systems of
education, health, social, employment and legal spheres, who attend to people who are
suspected of being or who show evidence of BIF in the areas of detection and diagnosis. The
aim is to facilitate the coordinated action of these professionals, thus improving the care
given to people with BIF. Furthermore, a specific section is included in the field of legal
medicine and forensic science.
The document also includes a brief explanation of the resources involved in detection and
diagnosis processes and a section with an explanation of the screening instruments that
enable the identification of borderline intellectual functioning suspicions.

Process of detection and diagnosis

The following graph provides a schematic overview of the detection and diagnosis processes
which are discussed in more detail in this chapter:

18
1. Detection process and alarm signals
Alarm signals are understood to be signs, symptoms or sets of manifestations which, if
present at a certain age, should raise suspicions about BIF.

1.1. Children and young people

The detection of children with a high risk of BIF should be carried out as soon as possible so
that interventions in education, health and social contexts can be adapted to their needs. To
do this, it is vital that the professionals working with children and young people be aware of
the alarm signals.

The detection of risk factors and alarm signals of BIF can be done on the basis of direct
observation of the child's behaviour or on the basis of reports from the family or professionals
in education, health or social spheres who are in contact with the child and/or the family.

Child development should be closely monitored routinely within the protocol of preventative
activities and health promotion activities (‘Healthy Child Programme’) carried out in primary
health care during the paediatric age, and in preschool educational contexts.

When there is any concern or suspicion that the child is not following normal levels of
development, and given the presence of alarm signals, a specific assessment should be
carried out to confirm the diagnosis.

The main alarm signals that professionals in the different centres working with children and
young people should be aware of are described below.

1.1.1. Nurseries and schools

The observations carried out by preschool teachers and school teachers of children during
learning activities, games and communication tasks are very useful in the case of BIF
suspicions.

In these environments, alarm signals are:

 Low level of comprehension,

 Poor verbal expression,
 Difficulties in mathematical processes and reading and writing,
 Difficulties in the symbolisation process,

19
 Lack of attention and concentration,
 Low tolerance of frustration,
 Lack of initiative,
 Need to stick to rules,
 Low exploratory behaviour and lack of curiosity.

Detecting the presence of these alarm signals as soon as possible and specifying the
characteristics present (intensity, triggers, inhibitors...) helps to provide relevant information
to be passed on to specialised services.

When a teacher detects the presence of alarm signals, they must refer the case to the Early
Childhood Care and Development Centres (ECCDC) in the case of preschool environments,
and, in the case of schools, directly to the Psychopedagogical Assessment Team or Primary
Healthcare professionals for them to confirm or rule out the suspicion of BIF through
psychopedagogical assessments (PAT) or diagnosis (PHS).

1.1.2. Secondary Schools

The learning or relational difficulties mentioned in the previous section may sometimes go
unnoticed or be only moderately evident in preschool and primary education. As a result,
students who have BIF but have not been diagnosed continue to be expected to perform like
other students at school, without receiving any additional support. Because of this, students
with BIF end up failing at school, which can lead to disruptive behaviour or inhibitions, or can
turn into behavioural disorders.

In Secondary Education, the alarm signals are:

 Information on learning difficulties on completing primary education,

 School failure,
 School failure associated with symptoms of depression and/or anxiety,
 School failure associated with behavioural disorders.

When a teacher detects the presence of alarm signals, they must refer the case to the
Psychopedagogical Assessment Team or the Psychopedagogical Advisor at the school, or to
Primary Healthcare professionals for them to confirm or rule out the suspicion of BIF through
psychopedagogical assessments (PAT) or diagnosis (PHS).

20
1.1.3. Primary Healthcare Services (PHS)

Paediatricians, doctors, and nurses must identify risk factors and alarm signals during the
routine check-ups of the ‘Healthy Child Programme’ within primary healthcare services, and
they should also take into account any reports made by families in relation to the risk factors.

The following points should be taken into account during paediatric check-ups:

 Detection of changes in neurological development,

 Information relating to school performance,
 Behavioural changes, especially in the school sector,
 Factors concerning families.

1.1.4. Early Childhood Care and Development Centres (ECCDC)

From the early stages of life, ECCDC professionals must identify risk factors and alarm
signals in children attending the centre who present difficulties in development.

When a child with alarm signals comes to the end of the care period in the ECCDC, and
before being signed of this particular service, a cognitive test should be carried out with a
psychometric test to determine their IQ, with oral and manipulation tests, and also assessing
their functioning in other areas (see section 5 of this chapter).

1.1.5. Psychopedagogical Assessment Teams (PAT) and Secondary

School Advisers

Psychopedagogical Assessment Teams (PAT) and secondary school advisers must consider
the alarm signals of BIF when they receive a request to assess a student from teachers
based on the alarm signals described in sections 1.1.1. and1.1.2.

In such cases, they should carry out the psychometric and functional assessment of the
student with the instruments described in section 5 of this chapter.

21
1.1.6. Child and Adolescent Mental Health Centres (CYMHC)

When a CYMHC provides care services for a child or young person referred directly from a
primary healthcare centre (PHS) or from a primary or secondary school or ECCDC, an
assessment should be made of their intellectual capacity using the instruments described in
section 5:

 Whenever there is a learning disorder,

 With any other psychopathology with a history of school failure or difficulty adapting to
school.

In patients referred from ECCDCs with any kind of psychopathology and diagnosis indicating
a probability of a borderline IQ, the assessment should be repeated at 8-9 years old.

1.2. Adults
During adulthood, people with borderline intellectual functioning have more difficulty
resolving problems, whether at work or in personal relations, which often lead to constant
failure at holding down a job or in their social and family relations, and to a greater presence
of behavioural changes or mental illness.
They show difficulties in executive functions, i.e. in the skills needed to organise, plan and
direct their behaviour towards their goals smoothly and efficiently.
They have problems:
 Behaving in a purposeful way,
 Resolving problems in a planned and strategic way,
 Paying attention to the different aspects of a problem at the same time,
 Problems paying attention in a flexible way,
 Suppressing spontaneous tendencies that lead to errors,
 Retaining the information needed to carry out an action in their working memory,
 Getting the gist in a complex situation.

Primary Healthcare Services, tertiary healthcare services or social services that detect any of
the difficulties mentioned should refer the person to the Adult Mental Health Centre (AMHC)
or the Specialized Service in Mental Health for People with Intellectual Disability (SSMHID).

22
2. Diagnostic process
This section describes the characteristics of the process of confirming the BIF diagnosis in
each of the teams involved in assessing people who present alarm signals. The confirmation
of the existence of BIF is carried out by the professionals on the following teams:

 ECCDCs for children already cared for by the ECCDC for other reasons, and for children
referred from a preschool or primary healthcare centre (PHS).
 PAT for children and young people in primary and secondary schools. In secondary
schools, the psychopedagogical advisor can also confirm the diagnosis.
 CYMHCs, for children and young people already treated in the CYMHC for other
symptoms, or referred by primary healthcare centres (PHS) or from primary and
secondary schools following a report from the PHS.
 AMHCs, in adults already treated in the AMHC for other symptoms, or adults referred
from the primary healthcare service, from tertiary healthcare centres, or from social
services.
 SSMHIDs, in adults already treated in the SSMHID for other symptoms, or adults referred
from the primary healthcare service, from tertiary healthcare centres, from AMHCs or
social services.

While an IQ of between 71 and 85 is sufficient to establish a diagnosis of BIF, this score

does not provide us with a description of behaviour or executive functions (Artigas et al.
2007), which are essential to be able to adapt to the environment beyond the score obtained
in the intelligence test. It is because of this that a more comprehensive study is needed to be
able to describe and understand how these people process information and adjust their
behaviour, as detailed in section 5, ‘Screening and identification’.

2.1. Child and adolescent population

2.1.1. Child development centres and early intervention (ECCDC)

A closed diagnosis is not provided in early childhood, with the emphasis being on the risk of
BIF.

Preschool centres and Primary Healthcare Services (PHS) that detect alarm signals in a
child must refer the case to the ECCDC for them to confirm or rule out the diagnosis of Risk
of BIF.

23
The diagnostic process to be followed is as follows:

 Regarding the diagnosis:

1. Pass psychometric and functional tests to assess the overall development of the child
(see section 5 of this chapter).
2. Draw up the report with the diagnostic impression of the risk of BIF (see section 5).

 Regarding therapeutic attention:

1. Establish coordination with paediatricians, psychopedagogical assessment teams

(PAT) and social services.
2. Maintain constant coordination with families to inform them of the diagnosis and
treatment guidelines.
3. Before the end of the attention provided by the ECCDC commensurate with age, a
cognitive assessment should be carried out, with a psychometric test to determine IQ,
verbal and manipulative tests with the instruments explained in section 5 of this
chapter, and a quantitative and qualitative analysis of the results obtained.
4. If other behavioural or emotional difficulties are identified, the case should be referred
to the CYMHC.

2.1.2. Secondary school educational psychology assessment and

guidance (PAT) teams

During the psychopedagogical assessment of students at risk of BIF, the PAT professional or
advisor of the secondary school should ensure that there are no other causes such as, for
example, sensory alterations that justify the difficulties shown by the student, and must also
make sure that the student has received school learning opportunities in line with their age.

The PAT or school advisor should check their IQ and any difficulties in adaptive behaviour,
whether cognitive, social or practical, using the instruments included in section 5 of this
chapter.

This assessment is carried out in a naturalistic context with contributions from teachers who
know the student, other external professionals involved and the participation of the family.

If the PAT monitors a student diagnosed by the ECCDC as at risk of BIF, the team should
confirm or rule out the existence of BIF during the psychopedagogical assessment carried
out in the 3rd year of primary education.

24
In any event, the psychopedagogical assessment carried out by the PAT should guide
schools in the measures and support needed to provide educational attention in a way which
is adapted to the needs of students with BIF.

The diagnostic protocol to be followed by the PAT is as follows:

1. Conduct psychometric and functional tests to assess the overall development of the child
or young person (see section 5 of this chapter).
2. Draw up the report on BIF, or the risk of BIF, in line with the results of the assessment.
3. Inform the family of the result of the assessment and of the proposed care plan.
4. Establish coordination with paediatricians, ECCDC, CYMHC and social services.

2.1.3. Child and youth mental health centres (CYMHC)

The care given to a child or young person referred to the CYMHC by the primary healthcare
services (PHS) is as follows:

1. Application of the BIF diagnostic criteria, using the instruments included in section 5 of
this chapter.

2. Before the end of the attention provided by the CYMHC in patients with BIF, another
assessment should be carried out at the age of 18, with instruments standardised for use
with adults, as detailed in section 5 of this chapter, as long as they have not been re-
assessed in the last two years.

2.2. Adult population. Detection and diagnosis

In the access to care services in the adult population, we make a distinction between people
already identified as having BIF, from the network of child and youth care services, and
adults who have not been identified and are already treated by the mental health network
(due to a mental illness and/or behavioural problems) or those who access the services for
the first time.

 People with BIF who have already been identified and have been treated by the child and
youth mental health network or the network specialised in intellectual disability (ID) and
mental health:

25
 1. Professionals of the child and youth mental health network should coordinate with
professionals of the adult mental health network to ensure that the correct referral
procedure is followed when referring from one network to the other.

2. If people are receiving attention in the network specialised in ID and mental health,
they should continue to receive care in this network.

 People with non-identified BIF. Detection can take place in different services:

1. Primary Healthcare Services,

2. Specialised services in mental health,
3. Social Services,
4. Other services and third sector providers.

In both cases, it is important that the diagnosis and assessment is carried out by
professionals, and that they be registered using diagnostic coding (CIE-9: V 62.89). This is a
basic recommendation to help create a shared census among social and health service
professionals.

2.2.1. Adult Mental Health Centres (AMHC and SSMHID)

In adult mental health centres, the same protocol is applied as with CYMHCs, in relation to
the diagnostic criteria to be followed and the completion of the attention period (see section
2.1.3.)

26
3. Legal and forensic medicine
According to the Civil Code, the whole or partial modification of a person's legal capacity can
only be implemented by means of a legal ruling. In order for this to occur, there needs to be
evidence of a physical or mental illness or deficiency of a permanent nature that stops the
person from being able to self-govern. In practice, this would mean that a whole series of
medical and social documents would need to be submitted to prove the presence of a
physical or mental deficit and the development of the person in society.

3.1. Detection
Within the protocol followed in family applications to modify a person's capacity to act, or in
legal processes, a psychometric and functional assessment should be carried out.

The following points should be taken into account in this assessment:

1. Vulnerability:

 Social and economic precariousness,

 Disengagement from family or lack of significant family,
 Inappropriate use of money,
 Evidence or suspicion that the person is being manipulated by others or that they are
making decisions for them (very important in cases of complex and elaborate crimes).

2. Assessment of different areas of the person's capacity:

 Decisions that influence their health and their participation in research: Informed
consent, consent/rejection of treatment.
 Decisions related to assets:
 Important personal assets such as money or financial assets, sales, swaps,
company shares.
 Personal assets of lesser importance such as small payments, regular payments
of electricity and gas bills, or travel and holiday fees.

3. Other areas to take into account:

 Autonomy in daily activities and travel,

 Need for protection in everyday activities,
 Capacity to enter into marriage.

27
4. Mental skills related to mental competence:

 Skill or capacity to express a choice,

 Capacity to understand information,
 Capacity to assess the meaning of this information in relation to their own situation
and the consequences of the different options,
 Capacity to employ reason to understand the relevant information.

3.2. Diagnosis
To draw up a forensic medical report in penal and civil cases, the basic protocol is as follows:

1. Personal background:

 Medical: to include a birth report, subsequent development and paediatric check-ups.

 Reports from the ECCDC, CYMHC, AMHC or SSMHID.

2. School reports,

3. Social services reports: these are very helpful in assessing the patient's functionality,

4. The assessment should be completed with an interview with the family,

5. Interview or medical history of patient following the structure indicated below:

 Biographical data,
 Reason for the examination,
 Personal somatic, psychiatric and toxicophilic background,
 Family background,
 The most relevant personal details are: the birth, psychomotor development,
childhood/adolescence, school, further academic studies, work, affective relations
and factors that may have contributed to or precipitated the appearance of mental
illness.
 It is most important to note: psychosocial learning; behaviour with others; skills in
relations and acquisition of new friendships; motivation; personal autonomy skills:
hygiene, order and cleanliness at a personal level and in their environment, meals,
leisure.

6. Psychopathological exploration,

7. Psychometric explorations:

28
  Psychopathology: MMPI-II, SCL-90,
 Personality disorders: MCMI-III, MMPI-II, Minimult,
 Intelligence: RAVEN, TONI-2, WAIS - III.

8. Medical-legal considerations,

 Degree of personal autonomy,

 Ability to adapt,
 Ability to communicate,
 Functional repercussion,
 Responsibility.

29
4. Resources involved in detection and diagnosis
processes
Different ordinary and specialised resources are involved in the detection and diagnosis
processes described in this chapter, as shown in the graphic summary provided below:

Ordinary resources

Resources that are found in the ordinary environments of relations, learning and health
regulations for children, adolescents, young people and adults. The work carried out by the
professionals in these fields is essential in the process of detecting the first alarm signals of
the existence of BIF.

 Education: nurseries, schools (preschool stage from P3-P5 and primary PE1-PE6),
secondary schools and adult education institutes;
 Health: Primary Healthcare Services (PHS).

30
Support or specialised services

These are involved in the processes of detection, psychopedagogical assessment and

diagnosis, and offer support and guidance for people with BIF and their families.

 Education: Psychopedagogical Assessment Teams (PAT) and secondary school

advisers;
 Work, Social affairs and Families: Early Childhood Care and Development Centres
(ECCDC);
 Health: Child and Youth Mental Health Centres (CYMHC), Adult Mental Health Centres
(AMHC) and Specialised Service in Mental Health and Intellectual Disability (SSMHID);
 Legal: Institute of Legal Medicine and Forensic Sciences of Catalonia.

Other resources

Other resources related to detection and diagnoses are included in other chapters of the
document. For example, the Catalan Employment Service (SOC), Care Centres for People
with Disabilities (CCPD), and Labour Assessment and Orientation Teams (LAOT), see
chapters VI and VII.

31
5. Screening and identification
Intellectual disability (ID) is an issue which has been debated intensely in relation to its
denomination, conceptual definition, and the criteria used to classify it (Salvador Carulla &
Bertelli, 2008). As a result, the BIF concept cannot be understood without detailed reference
to the concept and classification of ID.

Thus, in the case of any suspicion of BIF, a numerical assessment of intelligence must be
made, as well as an assessment of the functionality of the person at risk of BIF.

5.1. Screening and identification phase

The screening and identification phase must incorporate a comprehensive and
multidisciplinary system that uses the same instruments to identify suspicions of Intellectual
Functioning and Adaptive Functioning below the population mean in a sensitive way,
especially for people at risk for BIF or who may present complex and concurrent social and
health needs.

While acknowledging the operational and functional value of the different diagnostic
instruments available, one single instrument has been selected to assess each of the
dimensions shown in the table below. Some of the instruments selected—which are
presented briefly below—are also cited in the Manual and others are used extensively
among professionals in the different fields.

Dimension Instrument

Cognitive screening assessment K-BIT

Complete cognitive assessment WISC-V (children) WAIS-IV (adults)

Functional Assessment and Adaptive Behaviour ICAP

Mental Health and Behavioural Assessment HoNOSCA (children) – HoNOS-DI (adults)

32
5.1.1. Cognitive Assessment (Intellectual Coefficient)

The prior use of the instrument known as K-BIT is proposed as a ‘screening’ tool in new
cases in which there has been no previous intervention from the mental health network: it is
quicker to process, and if the result is positive and a possible case of BIF is detected the next
step would be WISC-V (children) or WAIS-IV (adults).

K-BIT Brief intelligence test by Kaufmann

The K-BIT is designed to measure the general intelligence of a wide age-range of individuals
(from 4 to 90 years old).

It is quick and easy to apply (between approximately 15 and 30 minutes), making it an

excellent tool to carry out the ‘screening’ required to make a quick assessment of general
intelligence and also to provide data to help decide whether a more in-depth evaluation is
needed.

It is made up of two subtests:

 Vocabulary: Measures the verbal ability needed to give oral responses. Assesses verbal
skills, language development, the formation of verbal concepts and the flow of
information.
 Matrices. Measures non-verbal skills and the capacity to resolve new problems.
Assesses the capacity to resolve reasoning problems through visual, figurative and
abstract stimuli.

The application of the K-BIT provides the professional with a verbal intellectual coefficient
(IQ), a non-verbal IQ, and a compost IQ that sums up the person's overall performance in the
test.

Furthermore, none of the tests require a motor response, meaning that it can also be applied
to people with any kind of physical impairment.

The regulations for interpreting the K-BIT are straightforward. The test itself has a simple
system for interpreting the scores obtained in each subtest.

33
WISC-V scale

The Wechsler Intelligence Scale for Children (WISC) is a scale for assessing intelligence and
intellectual aptitude in children in clinical and psychopedagogical environments. Developed
on the basis of the Wechsler-Bellevue scale, it was designed by David Wechsler to be
applied to people under 16. It comprises two subscales—verbal and manipulative—each of
which contain six subtests. As with the WAIS, it provides us with an overall score called the
Total Intelligence Quotient.

WAIS-IV scale

WAIS is a test designed to assess overall intelligence, understood as an IQ concept, in

individuals between 16 and 64 years old, of any race, intellectual level, education, socio-
economic and cultural level and reading level.

It is individual and contains two scales: verbal and execution. It is based on Spearman's
bifactorial theory of intelligence, taken from a global perspective, since it comprises skills
which are qualitatively different (traits), but not independent. However, the sum of these skills
is not only expressed in relation to their quality, but also in relation to non-intellectual factors
such as motivation. Intelligence involves a certain degree of overall competence.

BIF criteria results

K-BIT, WISC-V and WAIS-IV scale: Intellectual coefficient between 71 and 85.

5.1.2. Assessment of Adaptive Functioning

The BIF concept associates different cognitive dysfunctions with an intellectual coefficient of
between 71 and 85, which result in deficits in the person's functioning both in terms of the
restriction this implies on the activities they can carry out, as well as in terms of their social
participation. It should be noted, therefore, that cognitive deficit is not solely restricted to a
simple question of IQ, which is why it is necessary to carry out an accurate assessment of
the person's adaptive functioning.

34
ICAP Inventory for Planning Individual Services and Programming

This is a tool which, among other things, enables standardised assessments to be carried
out of adaptive behaviour and behavioural problems.

In essence, the ICAP comprises a systematic register of relevant data on the person
receiving attention by a particular service and two regulated measurement instruments: one
on adaptive behaviour and another on behavioural problems. The ICAP is applicable to
people of all ages and is basically designed to be used for people with disabilities, although it
can be used with other population groups who are sometimes excluded from the previous
category; for example minors with marginalisation problems, the elderly, people with mental
health problems, people with Borderline Intellectual Functioning, etc.

The ICAP consists of:

 A register of the diagnosis or diagnoses of the person, personal details, functional

limitations (mobility, vision, hearing and general state of health).
 An adaptive behaviour test that measures the person's level in relation to the basic skills
needed to live independently in their environment which is structured according to four
scales:

1. Social and communication skills (both expressive and receptive language).

2. Personal Life skills (independence in relation to the most immediate personal needs
such as eating and dressing).
3. Community Life skills (for example, the autonomous use of public transport, the
person's ability to use money or a watch).
4. Motor skills (fine and gross).

Standardised scores are provided for each scale, as well as a general one which
encompasses all the others: age, percentiles and typical scores, among others. In addition, it
is also possible to establish a Profile of Instructional Implications in which two ages are
obtained, from which the content of the specific programmes targeted at the people
assessed can be adapted, in such a way that the level of difficulty is not perceived as either
too easy or too difficult by the person.

A behavioural problem test, which analyses a person according to eight areas, from which
four standardised indexes of behavioural problems are extracted. Internal, Antisocial,
External and General.

The ICAP is a relatively simple and quick test (20 minutes when the professional is familiar

35
with it) that can be completed independently (self-administered) by someone who knows the
person being assessed. Any professional with the most basic experience in completing
questionnaires can fill in the ICAP (teachers, monitors, social workers, psychologists, etc.).
The interpretation of the ICAP and the decisions taken subsequently about the person
assessed should be made by qualified professionals.

A version has been adapted to and validated for the Spanish population. (Montero, 1996).

BIF criteria results

Level of Service score of the ICAP scale 7 - 8: Limited attention to the person and/or periodic
monitoring.

5.1.3. Assessment of Mental and Behavioural Health as well as the

person's needs

“HoNOSCA” scale

The HoNOSCA scale (The Health of the Nation Outcome Scales for Children and
Adolescents) is an outcomes measure designed to be used in mental health services treating
children and adolescents below the age of 18. It is focused on general health and social
functioning.

It includes 15 items that measure behaviour, deterioration, symptoms and social functioning.
The items are classified on a scale of 0-4 and the results or changes in scores can be
attributed to the services received. The score is obtained using a glossary with detailed
descriptors of the level of seriousness and complexity. Information from all available sources
should be taken into account when filling in the qualifications, including the user of the
service and their family.

“HoNOS-DI” scale

The Health of the Nation Outcome Scales for People with Learning Disabilities (HoNOS-LD –
Roy, A.; Matthews, H.; Clifford, P.; Fowler, V.; Martin, D. M., 2002), is an instrument
comprising a set of scales designed for people with intellectual disabilities and mental health
problems. It was designed to obtain an overall index of functioning.

36
It was developed on the basis of another instrument: Health of Nation Outcome Scales
(HoNOS – Wing, J.K.; Curtis, R. H., Park, S.B.G.;Hadden, S.; Burns, A., 1998). This was
developed by the Research Unit of the Royal College within the framework of the Health of
the Nation project of the British Department of Health. It comprises scales designed to
measure different physical, personal and social problems associated with mental illness. The
instrument was designed by the government administration by Mental Health professionals,
to be used routinely in a clinical context.

The HoNOS-DI is a brief scale comprising 18 items, which assesses the problems frequently
presented by people with intellectual disabilities in different spheres. It is made up of four key
areas: behaviour, cognition, clinical problems and daily life activities. Specifically, it includes
behavioural problems (auto- and hetero-aggression, impulse control), problems associated
with cognitive deficits (attention, concentration, memory, orientation and communication),
affective problems, hallucinations and delirium, health problems, problems related to
autonomy and problems in the social sphere. The highest score possible is 72. The higher
the score, the more serious the case.

A version has been adapted to and validated for the Spanish population. (Esteba-castillo, S.;
Torrents-Rodas, D.; García-Alba. J.; Ribas-Vidal, N.; Novell-Alsina, R, 2016).

5.2. Criteria for differential diagnosis

Finally, apart from screening, in the case of non-identified adults, criteria for differential
diagnosis should be considered. The idea of such criteria is to avoid cases in which IQ may
conceal cases that are not BIF, but which present similar levels of IQ. Such criteria would be:

 That there is no history of chronic mental illness without cognitive deficit.

 History of chronic use of psychiatric medication
 Age range: in order to rule out the possibility of secondary cognitive deterioration,
evidence must be provided that the cognitive deficit started before 18 years of age.
 That there is no history of previous cranial trauma, secondary brain damage as a result of
an incident or a process of early dementia.

37
5.3. Diagnostic assessment instruments

Instruments Age

Verbal and non-verbal intelligence tests

BSID. Bayley scale of infant development 0 - 2.5

MSCA. McCarthy's Aptitudes and Psychomotricity Scale for 2.5 – 8.5

children
WISC-V. Wechsler's Intelligence Scale for children 6 – 16.9

WIPPSI. Intelligence scale for preschool and primary education 4 – 6.5

K-ABC. Kaufman's assessment battery for children 2.5 - 12.5

K-BIT Brief intelligence test by Kaufmann 4 - 90

Non-verbal intelligence tests

Raven's Progressive Matrices Test 12 - 65

TONI-2. Non-verbal intelligence test 5 – 85.9

Leiter – R 2 – 20.9

Adaptive Functioning Assessment

Inventory of adaptive skills (CALS), curriculum of adaptive skills

(ALSC), and inventory to plan individual services and
programmes (ICAP).

38
V. Individualised intervention plan

39
1. Children and adolescents diagnosed with BIF or as
being at risk for BIF
Care for people with BIF should be individualised and focused on their needs, with a
comprehensive and holistic perspective that takes into account health, social and educational
aspects. For this reason, people with BIF and their families are provided with an
Individualised intervention plan with an interdisciplinary approach that guarantees that a
single key worker is assigned to the case to ensure personalised monitoring and the
coordination of the different services involved in looking after the case.

People with BIF have educational, social and employment difficulties similar to those of
people with intellectual disabilities (ID), but to a lesser degree. This section refers to the care
given to children and adolescents who have been diagnosed with BIF or at risk for BIF.

At each stage of development, the different resources provided by the Government of

Catalonia involved in attending to people with BIF in the educational, social and health fields
are listed.

1.1. Children between 3 Resources involved:

School - PAT - ECCDC - PHS - social services
and 6
Therapeutic plan

The ECCDC establishes a therapeutic plan for the child at risk of BIF which must be
interdisciplinary.

1. At a clinical level, intervention in the different areas of development:

 Cognition,
 Attention and memory,
 Communication,
 Language,
 Symbolisation,
 Emotional affective area,
 Fine and gross motor skills.

40
2. In work with families or guardians:

 Periodic interviews with parents (provide parenting guidelines, family habits, suitable
games for the child's age and stage of development...);
 Include the family in the sessions;
 Share the working objectives with the family;
 Promote relational strategies with parents;
 Recommend other community resources to the family.

Action in the educational field

At school, which is the most natural space in which the child develops, the steps to be
followed are as follows:

1. In addition to the universal measures implemented in the classroom, the school, with the
guidance of the PAT, should assess the merits of providing the child with any kind of
additional or intensive support.

2. The teaching staff should agree on the educational care measures to be taken,
depending on the level of functioning and learning of the pupil, and carry out appropriate
monitoring (class teacher, special education teachers, Attention to Diversity Team...) of
their development.

3. In school meetings with the family, the teaching staff and the family should agree on
specific and shared guidelines to follow and should monitor the progress and success of
these agreements.

4. The Attention to Diversity Team of the school, or the equivalent body, should be informed
of any support that the pupil is receiving.

5. On completion of preschool education, all information about the actions carried out and of
any support received by the student should be passed on to the primary school teacher.
It is recommended that these be registered in writing in the end of preschool report.

Coordination between the different resources involved

Coordination between ECCDC and the Education authorities

1. Inform the PAT of children at risk of BIF.

41
  At the time the risk is diagnosed if the child is already at school;
 When starting school;
 When starting to receive attention from the ECCDC.

2. Share clinical information about the child and the family to be able to work effectively
together. (Coordination meetings should take place every six months.)

3. Clinical report explaining the BIF diagnosis to the parents (including a cognitive and
functional development assessment) with degree of parents' awareness and acceptance
of the diagnostic guidelines.

Coordination between ECCDC and CYMHC

1. In cases of risk of BIF and behavioural changes and/or associated emotional changes,
the case should be referred to the CYMHC.

2. The end of care report from the ECCDC must include the day and time of the first visit to
the local CYMHC.

Coordination between ECCDC and Social Services.

If the patient at risk of BIF is considered to be at social risk or not receiving due attention
from their family, the ECCDC worker must inform social services.

Coordination between ECCDC and the Primary Health Service Paediatric Team.

1. On arriving at the ECCDC, the paediatrician should be informed of the start of care
services and the diagnostic impression.

2. When care services are ended, the paediatrician should be notified in the same way.

1.2. Children and young Resources involved:

people over 6. Primary or Secondary School - PAT - CYMHC
- PHS - social services

The treatment plan

A therapeutic plan is established by the CYMHC

42
1. The CYMHC intervenes when the child/adolescent presents a mental illness or
behavioural changes. In such cases, the specific intervention needed in accordance with
the disorder presented should be carried out, with aspects related to BIF also being
covered.

2. The intervention should include different levels:

 Behavioural: specific work on personal autonomy.

 Emotional: work on self-esteem, both in terms of limitation and capacities.
 Social: prevention of bullying at school, sexual abuse, drug consumption and other
addictive behaviour. Marginal groups.

3. In work with families:

 Psychoeducation on BIF: strategies for managing behaviour and emotions,

strategies for increasing functionality.
 Recommendations for avoiding risk of abuse.
 Support and strategies to facilitate structured and supervised contexts for the child at
risk of BIF.

4. In children that have been referred for a first visit from the ECCDC, the CYMHC must aim
to establish links with the resource. If the family fail to attend the visit, contact must be
established with the family by telephone. If no adequate response is provided, local social
services must be informed.

Action in the educational field

Children between 6 and 12 years old - Primary Education

During primary education, the steps to follow are the same as in preschool education, except
that:

1. The need for additional or intensive measures and support may become more apparent
and it may become necessary to specify them in an Individualised support plan (IP).

2. In the event that the PAT monitors a child diagnosed at risk of BIF by the ECCDC, during
the third year of primary education the risk indicators detected should be reassessed
(with a psychometric and functional assessment carried out by the PAT if significant
learning difficulties are present; or by the CYMHC if the problems are more general).

43
3. In the child already diagnosed with BIF, but who is not being monitored by the health
services, if behavioural or emotional difficulties are observed during the PAT
psychopedagogical assessment, the child should be referred to the local CYMHC.

4. If a child presents indications of social risk, the Social Commission of the school or an
equivalent body should monitor the case.

5. In the change from primary to secondary, the school should pass on information about
BIF students; notifying them if an IP is in place, or if monitoring has been carried out by
the PAT. The transfer should highlight the actions that have helped the pupil have good
learning experiences, in order to facilitate the continuity in secondary education. This
transition must be carried out providing support for the family through meetings with the
school and with the PAT if necessary.

Older children and adolescents over 12 - Compulsory Secondary Education

1. On the basis of the information provided by the primary school, the secondary school will
decide on the best educational attention for the pupil:

 Elaboration of an Individualised plan (IP) specifying the additional and intensive

measures and support mechanisms applied.
 Referral to PAT: If the PAT or school advisor monitors a child at risk of BIF who is not
receiving care from the CYMHC, the risk indicators detected should be reassessed on
completion of secondary school (carrying out a psychometric and functional
assessment).
 Development monitoring during secondary school.

2. If the child already diagnosed with BIF shows behavioural or emotional difficulties during
the PAT psychopedagogical assessment, the child should be referred to the local
CYMHC.

3. If a child presents indications of social risk, the Social Commission of the school or an
equivalent body should monitor the case.

4. Share agreements and monitoring with the family, as well as the actions carried out at
school and home in meetings held as frequently as is deemed necessary.

5. Inform the Commission for the attention to diversity of the child's school, specifying the
support the child is receiving.

6. The school will draw up a document of guidelines for the pupil in collaboration with the

44
 school advisor or the PAT if necessary, to ensure educational continuity and labour
orientation, taking into account the characteristics of the child with BIF: This document
must contain the most relevant aspects of the competency-based learning of the student
throughout their education.

7. If the child is receiving attention from another service external to the school (CYMHC,
Social Services...), the contributions made by these services will be taken into account in
the document.

8. The class teacher, school advisor and/or PAT, if necessary, will set up a meeting with the
family and the student to help in this transition.

Coordination between the different resources involved

The following coordination task will be carried out during the intervention:

Coordination between ECCDC and the Education authorities

Periodic coordination meetings for patients receiving care from the ECCDC should include
information related to BIF in patients with comorbidity:

 Intervention carried out by the ECCDC and development.

 Work with the family.

Coordination between ECCDC and Social Services.

Social Services: in cases where a social risk is detected, social services should be contacted
in order to monitor development. In such cases, referral to the Care Centre for People with
Disabilities should be considered, to assess if a disability certificate would be appropriate.

Coordination between ECCDC and the Primary Health Service Paediatric Team.

Primary health service paediatric team: the paediatrician should be informed about any
interventions carried out with the patient during inter-consultation meetings.

45
2. Adults with BIF and mental illness
As mentioned above, approximately 25% of people with BIF have psychiatric problems
related to cognitive deficits; with these being the main reason for them being in contact with
the Mental Health Network.

2.1. Intervention process

Care needs to be taken to ensure that adults with BIF who present mental illness and/or
behavioural problems receive support from the Mental Health Network (MHN), whether on a
general or specialised basis.

While there are many doubts about the benefits of using specialised services for intellectual
disability with people with BIF—since they can perceive this as a form of stigma—the
experience in Catalonia, after years of operation of the Specialised Network in Intellectual
Disability (ID), indicates that nearly 25% percent of people in this group may benefit from the
resources, services and support offered from this network (SSMHID and HUSID), (see
Quaderns de Salut, No. 5, Ministry of Health, Government of Catalonia, 2003).

Territorial Area of Catalonia Population

Adults ≥18 years old 5,979,952*

People with BIF (3% of adults) 179,398

People with BIF + Mental Illness (25% of people with BIF) 44,850

BIF population potential general MHN (75%) 33,637

BIF population potential specialised MHN ID (25%) 11,213

*Idescat 2016

46
2.2. Access to the Mental Health Network

Access to the Adult Mental Health Network (general and specialised) is governed by the
following criteria:

Users must meet criteria A+B+C+D or, if they do not meet these, follow the A+B+D pattern:
A. Aged 18 or over
B. Borderline intellectual functioning, understood as a deficit in different cognitive areas
(attention, language, memory, execution, knowledge, vision-perception...) that result in
difficulties in the correct execution of adaptive skills and social functioning. This deficit
will not be solely and etiologically secondary to mental illness. It should be noted that
the cognitive deficit cannot be exclusively limited to a simple question of IQ (70-84).

C. Evidence of mental illness defined by operational criteria such as ‘any diagnosis’

included in the DSM-5 or CIE-10 classification systems.

D. Presence of one or more instances of challenging behaviour2 which, due to their

intensity, frequency or duration, considerably limit the person from using community
resources.

2
Challenging behaviour is understood to be that which is socially unacceptable, the frequency, severity and duration of which
may pose a physical risk to the person, to others, or to their immediate surroundings; or may significantly limit their ability to
live their life in the most normal conditions possible, alienating them from more community-based environments. This
represents a social construct which is not included in the usual classification systems, and which means that all alterations in
a person with BIF are a challenge for the services, which must seek strategies to satisfy their complex needs.

47
2.3. Criteria for referring someone to the Specialised Network in
Intellectual Disability
1. Clinics:

 IQ between 70 and 84 (preferably between 70 and 75);

 Index of Behavioural Problems (ICAP) between -31 and -35;
 HoNOS-DI scale score ≥ 54 (Severe).

2. Social (psychosocial repercussions):

ICAP Scale Score: ≤ 5. (periodic attention to the person and/or frequent monitoring).

The social criteria to be used are as follows:

 Disturbance or limitation of a function (dysfunction).

 Functional incapacity (inability to develop a particular social role).
 Dependence (constant need to rely on a particular person or specific service).
 Manifest or persistent family overburdening or absence of family.
 Absence of social network.

As indicated above, the difficulties in accessing general services may prevent people with
BIF from developing and receiving the appropriate treatment. The aim of comprehensive
and multidisciplinary intervention, initially coordinated by SSMHID, is to guarantee that
people from this population group do not end up in ‘no man's land’.

The goal to achieve over the next few years, especially with the improvement of professional
skills in terms of the general network and improvements in the population register, is that the
percentage of people with BIF receiving services from the general network increases
progressively.

48
3. Social services
The attention and intervention provided by the Basic Social Care Teams (BSCT) respond to
the social needs manifested by the family or the person with BIF.

The intervention must always be through integrated approaches, incorporating the

coordination of the team and work carried out in the network with other services that provide
care for the child or person with BIF, such as the primary healthcare centre, mental health
services, educational institutions, local employment and housing services and any other
agents.

Interventions can be carried out on an individual, group or community basis according to the
care plan drawn up and its development.

In the case of BIF, the professional in charge of the case should always take into account
this coordination with specialised services. It is important that this professional acts as the
main interlocutor with the person, family, and other professionals involved, to ensure that the
care provided is comprehensive and consistent, and to channel the different services needed
appropriately.

49
50
VI. Employability

51
Access to the labour market is a basic right which provides human beings with self-esteem,
economic security and the independence needed to build an autonomous life.

The International Labour Organisation (ILO), the main objective of which is to promote
opportunities so that all people have access to productive work in conditions guaranteeing
freedom and dignity, recognises that work is a fundamental element in personal satisfaction,
social integration and recognition; and that having a decent quality job is the most effective
way of escaping the vicious circle of marginalisation, poverty and social exclusion
(International Labour Conference, Geneva, June 1999).

The Convention on the rights of Persons with Disabilities established in article 27 of the
United Nations convention, recognises that people with disabilities have a right to work in
equal conditions as others; this includes the right to the opportunity to earn a living by
carrying out a job which has been freely chosen or accepted in a labour market and work
environment that is open, inclusive and accessible to people with disabilities.

The BIF Consensus Manual exemplifies the practical experience of the employment of
people with BIF in Catalonia through its contracting policies in different departments of the
Catalan Government. This experience was developed through the coordinated efforts of the
Nabiu Catalan Association and the representatives of the Catalan Administration.

 Government Agreement of 11 November 1997 approving a project to manage the

employment of people with borderline mental deficiencies.

 Government Agreement of 21 October 1998, extending the number of workplaces

provided for in the Agreement of 11 November 1997, related to the project to manage the
employment of people with borderline mental deficiencies.

 Government Agreement of 15 June 1999 extending the project to manage the

employment of people with borderline mental deficiencies.

 Government Agreement of 29 May 2001 extending the employment project for people
with borderline intellectual disability and extending it to other groups of young people with
intellectual disabilities.

 Government Agreement of 27 May 2003 extending the employment project for people
with borderline intellectual disability and extending it to other groups of young people with
intellectual disabilities.

 Agreement proposal of the Catalan Government approving the public employment

provision for the year 2005, including 31 posts for the group and category E of general

52
 services assistant, for permanent staff working for the Ministry of Governance and Public
Administrations.

On the other hand, it is important to note that the State is responsible for establishing labour
competences and that, as a result, it is the Ministry of Employment and Social Security that
determines the policies to be followed, and that distributes the funds from the State's general
budget to the autonomous communities to carry out active policies targeted at the whole
population. In addition, it is also the State that regulates and legislates what to subsidise and
how to go about doing it.

The autonomous communities have little margin to act since the fact that the budget comes
from the central government means that their role is restricted to one of managing the budget
they are allocated. Actions aimed at promoting employment can only be carried out with the
autonomous community's budget and only after carrying out the common actions established
by the Ministry of Employment and Social Security. That means that autonomous
communities have little scope for activity and that the activity they carry out is subject to state
control.

The aim of this working group is to elaborate recommendations to improve the employment
of people with BIF.

People with BIF have special difficulties in receiving and exercising the rights they are
granted under the United Nations Convention on the Rights of Persons with Disabilities. They
need a period of adaptation and prior training to help adapt their potential skills to the socio-
labour realities they will need to face.

An intervention process has been defined within a comprehensive approach, which means
that the different departments involved in the process work together to facilitate the
employment of the person.

53
1. Intervention process for improving employability
In order to promote the employment of people with BIF, lifelong interventions are needed that
cover educational stages—when the person is being prepared to acquire the knowledge and
skills needed to be able to develop as autonomous a life as possible—up to adulthood, when
the person needs to find employment.

1.1. Coordination between school stage and labour stage

In accordance with the Individualised intervention plan (see chapter V) during the school
stage, it is important that people diagnosed with BIF receive suitable support to enable them
to make the most of their skills, as well as suitable guidance to make them aware of the
training that will improve their chances of finding employment, and guidance on the
employment and training resources that are the most suitable for their needs.

54
At secondary school, the class teacher, school advisor and/or PAT, if applicable, shall draw
up a guidance document on the training opportunities available to enable people with BIF to
make the transition to the labour market.

1.2. Labour stage

When the person with BIF reaches the labour stage, it is important to distinguish between
those diagnosed with BIF and those that are not diagnosed.

1. People diagnosed with BIF:

The Public Employment Service (SOC) will carry out the employability questionnaire and
refer the person to a specialised entity so that they can decide on the intervention needed
to gain employment.

2. People with BIF without a differential diagnosis:

In such cases, it is highly likely that the problem will not be detected and that the person
will not be referred to any kind of specialised entity. Because of this, it is recommended
that SOC staff receive appropriate training to be able to recognise the differential traits of
people with BIF and detect them in the initial interview.

In any event, to improve the opportunities of people with BIF, and to make the intervention
process more efficient, the Ministry of Work, Social Affairs and Families should make every
effort to ensure that people with borderline intellectual functioning (BIF) are recognised as a
differential group within active employment policies.

Specifically, the Ministry's funding bids for active policies, funded by the Catalan
Government, could specify the group of people with BIF as a specific group, in the same way
as with other groups.

Another action to promote the employability of people with BIF would be for the Ministry to
plan specific training that takes into account people with BIF.

And from the Ministry of Governance, Public Administrations and Housing, it would be worth
studying the possibility of recovering and updating the project to manage the employment of
people with borderline intellectual functioning initiated in 1997.

55
1.3. Accreditation of the BIF diagnosis
The BIF diagnosis can be accredited with a certificate issued by professionals working in
ECCDC, AMHC or SSMHID, on the request of the interested party.

Also at the request of the interested party, and after presenting a certificate of the BIF
diagnosis issued by a professional of the ECCDC, AMHC or SSMHID, a technical report of
the BIF diagnosis with a specific assessment of the disability can be requested from the
disability assessment teams of the Subdirectorate General for Attention to People and the
Promotion of Personal Autonomy of the Ministry of Work, Social Affairs and Families.

People with BIF who have also been issued with a certificate indicating degree of disability
may also access the resources and aid established in the regulations for people with
disabilities.

56
VII. Interdepartmental and
interprofessional coordination

57
1. Inter-service coordination
As explained in previous sections, the care model must be based on:

 Attention and overall assessment focused on the person, and considering the person as
a co-participant and as co-responsible for the planning, developing and assessment of
the care process, in line with their specific needs.

 Process of integrated assistance of all resources, adapting them to the individual needs
of each moment of the process.

 Management of the case, as a methodological framework that underpins the care

process and that necessarily entails a redefinition of professional leadership, the role of
the key worker and shared practices.

The management of the case must be designed to provide a broad-based response to the
needs of people with BIF, since different resources and professionals may need to intervene
in a coordinated way to ensure the continuity of care guided by one single Individual
Monitoring Plan (IMP).

Efforts must be made to ensure that all professionals of both the general and specialised
network who are responsible for and authorised to act in defining and providing the
necessary support work together in a multidisciplinary way to draw up the IMP.

In view of this, the figure of case manager is recommended, to coordinate between the
different professionals involved in the whole process and to be the main key worker
responsible for supporting the person with BIF and orienting their family.

In the case of people diagnosed with BIF and mental illness and/or additional behavioural
problems, the monitoring of the case from the health sector is also appropriate.

In such cases, the manager of the case should coordinate with the local coordinator of the
health sector within the context of two spaces:

 The monthly circuit meetings within the territorial framework of the Study and Referral
Group (SRG).

 Regular case monitoring meetings.

The existence of a local coordinator for each health region is proposed, preferably a member
of the Specialised Network in Intellectual Disability (social worker).

58
Functions of the local coordinator:

 Maintenance and constant updating of a register of people with BIF in the region,
specifying the use of services made by each client.

 Coordination with the Child and Youth Mental Health Network when referring the case.

 Coordination with the General Mental Health Network for adults.

 Invite the people involved in attending to the individual needs of the subject to
multidisciplinary territorial meetings (SRG), whether these be from the different networks
(General adult, specialised, or child and youth mental health, Employment, Social Affairs
and Families, Education, Justice and Third Sector), or the person affected or their legal
representatives.

 Keep the individual registers for each patient up to date. These registers should include
the reasons why the patient was provided with an IMP, the objectives, actions,
assessments carried out, etc.

 Person to oversee the care process and coordinate and be aware of the interventions
carried out by the different services and departments.

2. Recommendations on information and documentation

A shared and agile system for accessing information is needed, without comprising any
aspects in terms of the confidentiality of information or in relation to the need to respect the
rights of all users.

It is important that the reports issued by the different professionals involved in the process of
a case include information relating to the functional aspects of the individual and that all the
interventions carried out are mentioned in order to better focus and orientate the further lines
of action that need to be developed.

3. Care and support for families

While respecting people's decisions at all times, the role played by the family is also
important, insofar as this is the nucleus which can be key to promoting the functionality of the
person diagnosed with BIF.

59
Families must be supported during all stages of the intervention, in order to receive the
support and orientation necessary.

In all phases of the intervention it is necessary that:

 The relation of the person with the BIF diagnosis with the other people they live with is
known.

 The support network that the person and their family have is known.

 The case manager provides the person diagnosed with BIF and their family with all
information available (diagnosis, treatment, information on professionals).

 The family is accompanied in the referral to the services needed in each case (basic
social services, specialised educational services, disability and dependency assessment
teams, to manage access to certain resources if applicable).

4. Training for professionals

The availability of capable and experienced professionals is vital to improve the care given to
people diagnosed with BIF.

The training of professionals in the fields of psychiatry, psychology, nursing, education, social
work, direct personal care and primary care should be promoted.

With this goal, a training plan for these professionals is proposed across the whole territory.
This training plan should be developed by professionals within the network specialised in
people with intellectual disabilities.

Basic content of the training proposal:

 The concept of borderline intelligence functioning;

 How to detect BIF;

 The main mental illnesses in people with BIF (differences and similarities in relation to the
general population);

 Integrated approach to the needs of people with BIF.

More specific training is also recommended to be able to attend to people with BIF who also

60
have mental illness and/or behavioural problems.

The objective is to train professionals with responsibility for care services in Mental Health for
people with BIF to:

 Be aware of the main theoretical references in relation to people with BIF and mental
and/or behavioural changes.

 Acquire the skills needed to assess and diagnose mental and/or behavioural changes in
people with BIF.

 Acquire the skills needed to design and apply a biopsychosocial assessment which is
comprehensive and effective.

5. Existing resources
This section explains the different resources involved in the processes, ordered by
administration, and specifying at which age range they intervene.

Ministry of Labour, Social affairs and Families

Social Services Portfolio

Decree 142/2010 of 11 October approving the Social Services Portfolio 2010-2011.

The Social Services Portfolio is targeted at people in situations with special needs, such as,
among others, dependent people or those with disabilities, mental illness, drug dependency
and other additions, at risk of violence or youth crime, or subject to penal measures,
disadvantages, risks or social difficulties experienced by the elderly, children or adolescents,
exclusion or social emergencies, victims of sexism, discrimination or poverty.

It should be noted that people diagnosed with BIF with no other diagnoses are not granted
disability status or dependency status, according to the provisions of current legislation.

Therefore, it is important to highlight that people need to have been recognised as having at
least 33% disability in order to access residential resources or programmes. This
assessment is carried out by the assessment and orientation services. These services are
made up of assessment teams distributed across the whole of Catalonia.

61
If a person has been recognised as having the required level of disability as well as
dependency, the residential resources to which the person meeting this criteria can access
are as follows:

 Daytime care services for people with intellectual disabilities;

 Autonomy promotion services at home for people with intellectual disabilities;

 Residential care services for people with intellectual disabilities.

Catalan Employment Service - Training

Manages different measures, one of these being employment training. In this respect, they
offer courses targeted at unemployed people registered at Employment Offices of the
Government of Catalonia, programme pilot actions in new qualifications, and carry out
occupational tests to assess professional competence and issue the corresponding
certificates.

The main objective of the body is to be a source of reference within the field of employment
for both employed and unemployed workers.

It is important to note the recent Government Agreement 49/2016 of 26 April, approving the
directives of the Professional Accreditation and Qualification Plan which is to be developed.

Directorate General of Social Economy, the Third Sector, Cooperatives and Self-
employment - Employment

Manages employment insertion measures for people with disabilities and /or mental illness,
through subsidies for non-profit organisations and foundations and local corporations
specialised in this task.

62
Ministry of Education

Educational Institutions

Information on educational institutions can be found at the Ministry of Education website:

[Link]

Psychopedagogical Assessment and Orientation Teams (PAT).

PATs are assessment and psychopedagogical orientation teams that provide support for
teachers and schools in order to attend to student diversity and to students who present
special educational needs, as well as their families.

Ministry of Health

CYMHCs, AMHCs, and SSMHIDs

CYMHCs during childhood and youth and AMHCs and SSMHIDs during adulthood act as a
Primary Care Service of the Mental Health Network and are the gateway into this network.
These centres play a central role in providing care and assessment, for coordinating the case
once it has been assessed, and for deciding on the intervention needs in relation to other
resources:

 Day hospitals: partial hospitalisation resource for daytime care;

 Acute and Sub-acute Hospitalisation Units with full internment;

 Day Centres / Rehabilitation Services: intervention resources to improve relationship

skills and functional activities related to community life;

 SHUID: Specialised hospitalisation unit for persons' with intellectual disabilities in

collaboration with Social Affairs;

 Care Centres for drug-dependency (DDCC) in pathological situations of comorbidity with

substance abuse.

Alongside the Collaboration Programme established with the Primary Health Services, the
MHS coordinate to ensure intervention with the most suitable resources for each individual.

63
Ministry of Justice

Institute of Legal Medicine and Forensic Sciences of Catalonia.

The Institute is regulated by the following provisions:

Decree 411/2006 of 31 October, approving the Regulations of the Institute of Legal Medicine
of Catalonia. DOGC no. 4753.

Decree 279/2016 of 2 August, modifying the Regulation of the Institute of Legal Medicine of
Catalonia, approving Decree 411/2006 of 31 October, and its denomination as the Institute of
Legal Medicine and Forensic Sciences of Catalonia.7177.

Graph summarising existing resources.

AGE 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 >21

Justice ILMFSC

Basic Town

ECCDC
Social Affairs

Specialisations

CCD
children
CCD adults

LAOT labour
Government
institutions

School
Education

Adult education centres

PAT

SOC Training
Work
Work

Paediatrics
Basic
Adults

Health CYMHC

Specialisations AMHC

SSMHID

64
VIII. Glossary

65
Adult Mental Health These are outpatient care services specialised in psychiatric
Centres (AMHC) care and mental health for people over 18 who present
mental disorders in any of the developmental stages of
mental illness who, due to the seriousness and/or
complexity of their case, require additional care to that
provided through the primary healthcare services (PHS).

They also support the primary health services through

illness prevention programmes and by carrying out research
and delivering teaching programmes in mental health.

A Ministry of Health service.

Attention to Diversity This is the institutional space in which the school's

Team measures for attending to student diversity is planned,
where the monitoring of these measures takes place, and
where changes are reviewed and promoted to improve the
performance, state of well-being and success of all
students.

The team comprises the management team; the teachers

specialised in attention to diversity, special education
teachers, the school adviser, therapeutic pedagogy
teachers, support teachers, teachers from the linguistic
support class, professionals from the Special Education
Support Unit (SESU); the psychopedagogue of the
assessment and psychopedagogical guidance team (PAT)
and the coordinators or representatives of the different
teaching teams or stages, depending on the educational
stage.

A Ministry of Education service.

Basic Social Care The basic social care service comprises a set of
Teams (BSCT) professional actions that aim to attend to the most
immediate, general and basic social needs of individuals,
families and groups.

66
 These actions also help prevent social problems and
promote the reintegration of people at risk of social
exclusion.

The main functions of the technical teams that offer this

service are:

 To provide information, guidance, advice, community

social work, social and educational detection, prevention
and treatment.

 To make care proposals for people and for the

community, to design programmes of social actions, and
to cooperate with other services in the well-being
network.

 To have knowledge of the existing resources and social

provisions available and to provide information and help
individuals carry out formal procedures.

This is a municipal service

Borderline intellectual Borderline intellectual functioning (BIF) is a condition that

functioning (BIF) affects a considerable proportion of the population,
impacting on people's quality of life and on their social and
labour inclusion. Despite its social impact and frequency,
BIF is still not sufficiently recognised by health, social,
education, labour and legal systems at an international
level.

Care Centre for Persons Care centres for persons with disabilities (CCDs) provide
with Disabilities (CCD) information and guidance services for people with
disabilities, for their families, and for the community of
professionals who require such information. They are
distributed across Catalonia and each centre is allocated a
specific area of influence.

The centres host the assessment and orientation teams

(LAOT), composed of multi professional teams made up of a

67
 director, doctor, psychologist, social worker and
administrative personnel.

Catalan Public In accordance with Law 13/2015 of 9 July, in relation to the

Employment Service employment system and the Catalan Public Employment
(SOC) Service, the SOC is an autonomous body with an
administrative scope, assigned to the Ministry of Work,
Social Affairs and Families of the Government of Catalonia.

The work carried out by the SOC is framed within the

European Employment Strategy and the national plans for
work established by the State.

The main functions of the SOC are:

 To offer and provide services to anyone looking for work,
whether they are currently employed, unemployed, or
working for a company.
 To offer a framework of equal labour opportunities for all.
 To foster an entrepreneurial spirit and provide support for
small and medium-sized businesses.
 To ensure that dialogue and commitment among public
and private agents acts as the main driving force of
employment policies.
 To achieve high levels of employment through proactive
efforts, along with the promotion and creation of jobs.

Certificate of degree of The resolution on the recognition of degree of disability

disability (commonly recognised certificate) is the administrative
document that certifies a person's disability status. This
document facilitates the person's access to different rights,
services, programmes and services that aim to redress the
social disadvantages arising from their disability, or the
social barriers that limit their full and effective participation in
society.

In order to be able to access benefits for people with

disabilities, the individual must be recognised with a
disability level of 33% or more.

68
 The degree of disability is expressed as a percentage and is
carried out by applying Royal Decree 1971/199 of 23
December on the procedures for recognising, declaring and
qualifying degrees of disability.

An assessment is made of physical, mental, and sensory

disabilities and the communication and speaking skills
presented by the person, as well as any additional social
factors related to their family context, labour situation, or
education and cultural background that could hinder their
social integration.

Child and Youth Mental These are outpatient care services specialised in psychiatric
Health Centres care and mental health for people under 18 who present
(CYMHC) mental disorders in any of the developmental stages of
mental illness who, due to the seriousness and/or
complexity of their case, require additional care to that
provided through the primary healthcare services (PHS).

This service is included in the care system, being linked to

the other resources and with a coordination system that
facilitates ongoing care within the patient's therapeutic plan.

A Ministry of Health service.

Diagnostic The Classificació estadística internacional de malalties i

classification problemes relacionats amb la salut, 10a revisió (CIM-10), -
is the Catalan translation of the International Statistical
Clinical diagnostic Classification of Diseases and Related Health Problems,
category / Secondary Tenth Revision (ICD-10), of the World Health Organisation
category (WHO).

In Catalonia, the ICD-10 is mainly used to code causes of

death, as well as illnesses and health problems treated at
primary healthcare centres (PHCs) and primary healthcare
emergency services (A&E), among others.

This classification is part of the diagnostic and procedures

catalogue of the Systems Plan of the Catalan Health

69
 Service.

DSM-5 The Diagnostic and Statistical Manual of Mental Disorders,

DSM) of the American Psychiatric Association, or APA,
contains a classification of mental disorders and clear
descriptions of the diagnostic categories, to help clinics and
health science researchers diagnose, study and exchange
information to treat different mental disorders.

The current edition is the fifth - DSM-5 - which was

published on 18 May 2013.

Early Childhood Care Centres specialised in the comprehensive care of children

and Development up to six years old with development difficulties or disorders,
Centres (ECCDC) or at risk of suffering from them. As public care services,
they are available across the whole of Catalonia and work in
coordination with the other resources involved in providing
primary care for children.

Today, there are eighty six ECCDCs (including full-time and

part-time services, i.e. services that provide attention one
day a week) across the whole of Catalonia.

This service belongs to the Ministry of Work, Social affairs

and Families.

Hospitalisation unit A highly specialised hospital unit. The unit cares for adults
specialised in persons with intellectual disabilities who also present serious mental
with intellectual and/or behavioural disorders.
disabilities (HUSID)

Idescat The Statistical Institute of Catalonia (Idescat) is the body

responsible for official statistics in the region of Catalonia.
Created in December 1989 (Decree 241/1989 of 11
December). At present it comes under the Ministry of the
Vice-presidency and of the Economy and Finance, of the

70
 Government of Catalonia.

Intellectual disability Arising from significant limitations in intellectual functioning,

(ID) in adaptive behaviour and practical skills. It is characterised
by intellectual functioning below the mean, together with
limitations in two or more of the following areas of
adaptation skills: communication, taking care of oneself,
home life, social skills, use of the community, self-
management, health and safety, functional school contents,
leisure and work.

Intelligence quotient Intelligence quotient (IQ) is a score obtained after carrying

(IQ) out a standardised test to measure cognitive skills and the
intellectual capacity of a person (intelligence) in relation to
their age group. It is expressed in such a way that the mean
IQ of an age is 100 (a person with an IQ of 110 is therefore
above the mean of their age group; and a person with an IQ
of 90 is below the mean of their age group). The most
normal case is that the standard deviation (σ) of the results
is between 15 and 16, and the tests are designed in such a
way that the distribution of the results follows a Gaussian
distribution, which is to say that it follows a normal curve.

MH&AN - Mental Health The Mental Health and Addictions Network is the public
and Addictions Network network specialised in providing mental health care. It
provides total or partial hospitalised care and community
care services that are provided through adult and children
mental health centres and addictions centres or community
rehabilitation centres.

Primary Health Service The Primary Healthcare Service is the first point of access
(PHS) to the public health system. Patients are referred to other
services provided by the system from the primary care
service, except in the case of 061 CatSalut Respon or
through medical emergencies, which patients can access

71
 directly in the case of an emergency.

The Primary Healthcare Centre (PHC) is the place where

individuals should go when they have a health problem or
want to prevent an illness. The centre attends to and
diagnoses the main health problems, health and social care,
and health promotion services, preventative care, curative
care and rehabilitation, home care services, emergency or
ongoing care, and sexual health and reproductive care.

Primary healthcare services are part of the basic common

portfolio of care services which are completely covered by
public financing.

The primary care team (PAT) is the whole team of family

medicine professionals, including paediatrics, nurses,
dentists, social workers and citizens' advisers, who are
trained to offer comprehensive care, including the care and
promotion of health and education in healthy habits, the
prevention of illness, and guidance in relation to social care.

A Ministry of Health service.

Psychopedagogical PATs are assessment and psychopedagogical orientation

Assessment and teams that provide support for teachers and schools in order
Orientation Teams to attend to student diversity and to care for students who
(PAT). present special educational needs, as well as their families.

They are part of the Local Educational Services (LES),

together with the pedagogical resource centres (PRC) and
the Language, Intercultural and Social Cohesion
Assessment Teams (LISCT).

They provide services for schools, management teams,

teachers and other professionals involved in caring for
students with difficulties or special educational needs and
their families.

A Ministry of Education service.

72
Social Commission An interdisciplinary space that arises from the Diversity
Attention Team, where a record is kept of the demands
detected at school or in other services, as well as of any
social problems manifested, and where analysis and
reflection is carried out to agree on the diagnosis, decide on
suitable intervention and establish a monitoring process.

A Ministry of Education service.

Special Education These are resource units (human, technical and material)
Support Unit (SESU) that support schools to help them in the process of attending
to students with special educational needs in mainstream
schools.

Specialised service in These are outpatient care services specialised in psychiatric

mental health for people care and mental health for people of any age who present
with intellectual mental disorders in any of the developmental stages of
difficulties (SSMHID) mental illness who, due to the seriousness and/or
complexity of their case, require additional care to that
provided through the primary healthcare services.

This service is included in the care system, being linked to

the other resources and with a coordination system that
facilitates ongoing care within the patient's therapeutic plan.

It focuses its attention on patient and family care, but also

provides support for the care teams of special educational
centres and employment teams.

A Ministry of Health service.

Study and Referral A mixed body that coordinates the study and assessment of
Group (SRG) the needs of people with ID who present mental disorders or
behaviour in each health region, and that decides to refer
them to more suitable resources when the seriousness of
the case requires.

73
Ministries of the Government of Catalonia

These are the four ministers of the Catalan Government that are included in this
document:

Acronym Minister

EDU Ministry of Education

JUS Ministry of Justice

HEALTH Ministry of Health

LSAF Ministry of Labour, Social Affairs and Families

74
IX. Bibliography

75
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