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Investigating Low Adaptive Behaviour and Presence of the Triad of Impairments Characteristic of Autistic Spectrum Disorder as Indicators of Risk for Challenging Behaviour among Adults with Intellectual Disabilities

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Title: Investigating Low Adaptive Behaviour and Presence of the Triad of Impairments Characteristic of Autistic Spectrum Disorder as Indicators of Risk for Challenging Behaviour among Adults with Intellectual Disabilities
Language: English
Authors: Felce, D., Kerr, M.
Source: Journal of Intellectual Disability Research. Feb 2013 57(2):128-138.
Availability: Wiley-Blackwell. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8598; Fax: 781-388-8232; e-mail: cs-journals@wiley.com; Web site: http://www.wiley.com/WileyCDA/
Peer Reviewed: Y
Page Count: 11
Publication Date: 2013
Document Type: Journal Articles
Reports - Research
Descriptors: Autism, Pervasive Developmental Disorders, At Risk Persons, Behavior Problems, Adults, Mental Retardation, Disability Identification, Age Differences, Gender Differences, Foreign Countries, Group Homes, Adjustment (to Environment), Interaction, Speech Communication, Hyperactivity, Symptoms (Individual Disorders), Multivariate Analysis, Regression (Statistics)
Geographic Terms: United Kingdom (England), United Kingdom (Wales)
Assessment and Survey Identifiers: Aberrant Behavior Checklist, Adaptive Behavior Scale
DOI: 10.1111/j.1365-2788.2011.01524.x
ISSN: 0964-2633
Abstract: Background: Identification of possible personal indicators of risk for challenging behaviour has generally been through association in cross-sectional prevalence studies, but few analyses have controlled for intercorrelation between potential risk factors. The aim was to investigate the extent to which gender, age, presence of the triad of impairments characteristic of autism and level of adaptive behaviour were independently associated with level of challenging behaviour among adults with intellectual disabilities. Methods: Five datasets were merged to produce information on challenging behaviour, adaptive behaviour, presence of the triad of impairments, gender and age of 818 adults. Variables were entered into a multivariate linear regression, which also tested the interaction between the presence of the triad of impairments and level of adaptive behaviour. Results: Presence of the triad of impairments, level of adaptive behaviour, their interaction, and age, but not gender, significantly and independently contributed to the prediction of challenging behaviour. Presence/absence of the triad of impairments moderated the effect of adaptive behaviour on challenging behaviour. The inverse relationship found in the absence of the triad of impairments was virtually removed when present. Conclusions: This study has shown that it is necessary to control for intercorrelation between potential risk factors for challenging behaviour and to explore how interaction between them might moderate associations. (Contains 4 tables and 1 figure.)
Abstractor: As Provided
Number of References: 44
Entry Date: 2014
Accession Number: EJ1013061
Database: ERIC
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  Value: <anid>AN0084622605;eul01feb.13;2018Jul09.14:14;v2.2.500</anid> <title id="AN0084622605-1">Investigating low adaptive behaviour and presence of the triad of impairments characteristic of autistic spectrum disorder as indicators of risk for challenging behaviour among adults with intellectual disabilities. </title> <p>Background  Identification of possible personal indicators of risk for challenging behaviour has generally been through association in cross‐sectional prevalence studies, but few analyses have controlled for intercorrelation between potential risk factors. The aim was to investigate the extent to which gender, age, presence of the triad of impairments characteristic of autism and level of adaptive behaviour were independently associated with level of challenging behaviour among adults with intellectual disabilities. Methods  Five datasets were merged to produce information on challenging behaviour, adaptive behaviour, presence of the triad of impairments, gender and age of 818 adults. Variables were entered into a multivariate linear regression, which also tested the interaction between the presence of the triad of impairments and level of adaptive behaviour. Results  Presence of the triad of impairments, level of adaptive behaviour, their interaction, and age, but not gender, significantly and independently contributed to the prediction of challenging behaviour. Presence/absence of the triad of impairments moderated the effect of adaptive behaviour on challenging behaviour. The inverse relationship found in the absence of the triad of impairments was virtually removed when present. Conclusions  This study has shown that it is necessary to control for intercorrelation between potential risk factors for challenging behaviour and to explore how interaction between them might moderate associations.</p> <p>intellectual disabilities; risk indicators; challenging behaviour</p> <p>Challenging behaviour is relatively common among people with intellectual disabilities (IDs) who receive services. The prevalence of self‐injury, aggression and property damage among 91 164 people with IDs listed on a Californian service database was 14.4% (Borthwick‐Duffy 1994). Studies in England, Norway and Wales that have employed similar definitions to each other have shown the prevalence of challenging behaviour to be between 9.9% and 16.7% and the prevalence of more demanding challenging behaviour to be between 3.8% and 7.8% (Qureshi & Alborz 1992; Emerson et al. 2001a; Holden & Gitlesen 2006; Lowe et al. 2007). Challenging behaviour has also been found to be persistent over time. A number of longitudinal surveys have shown that the great majority of those identified as self‐injuring, being aggressive or damaging property at the first time point still did so 7 to 10 years later (Windahl 1988; Kiernan & Alborz 1996; Kiernan et al. 1997; Emerson et al. 2001b).</p> <p>Such challenging behaviour has important consequences. For example, people with severe challenging behaviour are vulnerable to exclusion from local services and removal to out‐of‐area placements, particularly if such behaviour includes criminal or inappropriate sexual acts or occurs in association with significant mental health needs or autistic spectrum disorder (Allen et al. 2007; Emerson et al. 2008). They may also be at higher risk of injury, antipsychotic medication in the absence of psychosis and of restrictive treatment, including restraint, seclusion and sedation (Emerson et al. 2000; Hawkins et al. 2005; Allen et al. 2007). Families and carers experience an increased burden of care, increased stress, strong emotional reactions, restriction of activities, risk of injury and deterioration in health (Jenkins et al. 1997; Kiernan et al. 1997; Mitchell & Hastings 2001; Hastings 2002; Allen et al. 2006). It is important to understand the factors that contribute to challenging behaviour as a prelude to finding effective ways of preventing or ameliorating it.</p> <p>In the absence of studies of the incidence of challenging behaviour among people with ID, evidence about possible personal indicators of risk for challenging behaviour has been derived from cross‐sectional prevalence studies (McClintock et al. 2003). In general, received wisdom is that challenging behaviour is more common among people who: (<reflink idref="bib1" id="ref1">1</reflink>) are male, albeit the association is more pronounced in relation to aggression and property destruction than other challenging behaviours such as self‐injury; (<reflink idref="bib2" id="ref2">2</reflink>) have greater severity of ID or needs for assistance; (<reflink idref="bib3" id="ref3">3</reflink>) are in their adolescence or young adulthood; (<reflink idref="bib4" id="ref4">4</reflink>) have certain syndromes, including autism; and (<reflink idref="bib5" id="ref5">5</reflink>) have restricted communication (Emerson 2001). However, indicators of risk vary across different topographies of challenging behaviour. McClintock et al. (2003) conducted a meta‐analysis of prevalence and cohort studies of challenging behaviour to identify potential risk markers. They concluded that aggression was associated with being male but self‐injury was not; self‐injury and stereotypy were related to severity of ID but aggression was not; self‐injury, property destruction and aggression were all associated with presence of autism, and self‐injury was associated with communication deficits but aggression was not.</p> <p>Subsequent studies (e.g. Crocker et al. 2006; Holden & Gitlesen 2006; Tyrer et al. 2006; Lowe et al. 2007) have tended to reinforce previous understanding, although their results are not entirely consistent. Holden & Gitlesen (2006) found that challenging behaviour as a whole was associated with severity of ID, adolescence and young adulthood, autism and impaired communication, but not gender. Lowe et al. (2007) reported that self‐injury was associated with autism, low adaptive behaviour, poor language development and poor social skills, but not gender. However, aggression and property destruction were not associated with any of these factors. Crocker et al. (2006) found that property destruction was associated with being male and severity of ID; verbal and physical aggression was associated with severity of ID, the former inversely, and self‐injury was associated with severity of ID and being female. Tyrer et al. (2006) only investigated physical aggression. They found it to be associated with being male, younger, more severely intellectually disabled and autistic.</p> <p>However, the findings above all stem from univariate analyses, either in terms of bivariate correlation with level of challenging behaviour or comparison of rates of challenging behaviour between groups separated by the variable in question. Where indicators of risk are themselves intercorrelated, such as between severity of disability, autism and social and communication skill deficits, determination of whether the factor confers risk in itself or whether it is only highlighted through its association with another factor needs more sophisticated analysis. There have been relatively few analyses that have investigated associations between potential risk factors and level of challenging behaviour, after controlling for the presence of other potential risk factors. Tyrer et al. (2006) used multivariate logistic regression to explore potential risk markers for physical aggression in addition to their univariate analyses. Associations with gender, age and severity of ID remained significant, but that with autism disappeared after adjustment for other factors. Similarly, Melville et al. (2008) found that an association between autism and level of problem behaviour ceased to exist after controlling for age, gender, severity of ID and presence of Down's syndrome. Cooper et al. (2009a) found that self‐injurious behaviour was independently associated with lower ability level, not living with a family carer, having attention deficit hyperactivity disorder, visual impairment and not having Down's syndrome. However, they did not find it to be associated with autism. In a related study of aggression, lower ability was again an associated factor but autism was not (Cooper et al. 2009b). In contrast, Totsika et al. (2011) found that the presence of autism and ID significantly and independently increased the odds for hyperactivity and conduct and emotional problems among children (5 to 16 years old), after controlling for age, gender, social adversity and maternal mental health. Levels of behavioural and emotional problems were greater among children with autism, with and without ID, than among children with ID alone.</p> <p>The purpose of the current analysis was to investigate the extent to which gender, age, presence of the triad of impairments characteristic of autism and level of adaptive behaviour (as a fine‐grain assessment of level of ID) were independently associated with level of challenging behaviour among adults with IDs using secondary analysis of existing data. In particular, the aim was to investigate the independent contributions of presence of the triad of impairments and level of adaptive behaviour, after controlling for age and gender, and to test whether one moderated the impact of the other. In order to maximise power, data were combined from four studies on staffed group homes (Jones et al. 2001 (baseline data only); Felce et al. 2002, 2003; Perry & Felce 2005) and a fifth study established through collaboration with 44 local primary health service providers to investigate health status and the impact of health checking (Baxter et al. 2006). Prior to pooling the data, individual and setting identifiers were inspected to establish where the same individuals contributed to more than one study. Any overlap was eliminated by deleting the records of individuals found in one database from subsequent databases. In addition, only people with no missing data were included.</p> <hd id="AN0084622605-2">Methods</hd> <hd id="AN0084622605-3">Participants</hd> <p>The database for the present study comprised 818 adults with an ID. Arising from the nature of the databases merged, most of the total sample lived in staffed group homes. Specifically, 31 lived independently, 143 in family placements and 644 in group homes. Two of the four group home studies (Felce et al. 2003; Perry & Felce 2005) were based on random samples of group homes for six or fewer people. Felce et al. (2003) drew a sample of 51 group homes from Wales and Perry & Felce (2005) drew a sample of 47 from South Wales and South West England. The third (Felce et al. 2002) had a convenience sample of 29 group homes, which were selected to have approximately equal representation of statutory, voluntary and private sector settings. The 74 group homes in the fourth study participated in research on the dissemination of an approach to staff training termed ‘Active Support’ (Jones et al. 2001). They were operated by three voluntary sector provider agencies who had agreed to nominate staff as ‘Active Support’ trainers. Selection of settings was biased towards those with residents with greater levels of disability, in keeping with the nature of the staff training. Only the baseline, pre‐training data were used for this secondary analysis. The one non‐residential study had a sample drawn from the lists of general practitioners agreeing to take part in an evaluation of health checking. The baseline, intake data were used in this analysis. They relate to 143 adults living in the family home, 140 in staffed group homes and 31 living independently. Although not a random sample, certain sample characteristics were in line with more general surveys of adults with IDs in the UK including age, adaptive behaviour, presence of challenging behaviour and distribution of place of residence (Baxter et al. 2006).</p> <p>Participants were on average 44.5 years of age (range 18–90 years, SD 14.7); 52.9% were male and 34.5% were assessed as having the triad of impairments characteristic of autistic spectrum disorder (n = 282). Mean score on the Adaptive Behavior Scale Part One (ABS; Nihira et al. 1993) was 167.9 (range 8–304, SD 68.9). The distribution of average percentile ranks across the 10 ABS domains spanned the deciles. The first and tenth deciles were under‐represented with 6% and 5% of the sample respectively. Otherwise, the proportions in each decile varied from 9% to 14%. Mean score on the Aberrant Behavior Checklist (ABC; Aman & Singh 1986) was 29.8 (range 0–131, SD 26.0).</p> <hd id="AN0084622605-4">Measurement</hd> <p>Information on age, gender, challenging behaviour, adaptive behaviour and the presence of the triad of impairments characteristic of autistic spectrum disorder was gained by research assistants recruited for the various studies interviewing carers who knew the participants well. Challenging behaviour was measured using the ABC (Aman & Singh 1986). This includes 58 items which cover five domains: irritability, hyperactivity, inappropriate speech, stereotypy and lethargy. The ABC has good psychometric properties (see Aman & Singh 1986) in terms of internal consistency (α range 0.86–0.94), inter‐rater reliability (r range 0.55–0.69) and test–retest reliability (r range 0.96–0.99). In the present study, a total score was used to indicate overall level of challenging behaviour and the domain scores to reflect different categories of challenging behaviour.</p> <p>Adaptive behaviour was measured using the ABS Part One (Nihira et al. 1993). The scale includes 73 items which cover 10 adaptive skill domains. A total score of all items was created to give a single dimensional score for adaptive functioning. Nihira et al. (1993) report content, criterion and construct validity along with internal consistency (Cronbach's α range 0.82–0.99), test–retest reliability (r range 0.88–0.99) and inter‐rater agreement (r range 0.83–0.99), which suggest that the ABS has good psychometric properties.</p> <p>Wing (1988) proposed that three specific impairments, later to be termed the triad of impairments, were associated with or characteristic of autism. These were in the areas of quality of social interaction, repetitive activities and lack of imaginative play. The triad of impairments served as the basis for the autistic spectrum disorder diagnostic criteria included in Diagnostic and Statistical Manual of Mental Disorders III Revised (Waterhouse et al. 1992). Presence of the triad of impairments was assessed using three sections of the Disability Assessment Schedule (DAS; Holmes et al. 1982): quality of social interaction, stereotyped behaviours and symbolic activities. Based on the Handicaps, Behaviours and Skills schedule (see Wing & Gould 1979), the DAS was designed to be used as a screening instrument of the abilities, disabilities and challenging behaviour of individuals with IDs. Quality of social interaction and symbolic activities are assessed under abnormalities of social and imaginative activities, which is reported by the authors to have satisfactory reliability (test–retest 82%, inter‐respondent: 68% and inter‐rater: 75–79%; Holmes et al. 1982). Similarly, the reliability of the stereotypy section is reported to be 77% for test–retest, 85% for inter‐respondent agreement and 80–82% for inter‐rater agreement. Threshold levels are reached by obtaining a score of 1 to 5 in overall quality of social interaction (including: does not interact – aloof and indifferent, interacts to obtain needs – otherwise indifferent, responds to – and may initiate –physical contact only, generally does not interact, but responds to social contact if others make approaches, and makes social approaches actively but these are usually inappropriate, naïve, peculiar or ‘bizarre’), a score indicating presence of stereotyped behaviours, elaborate routines, echolalia or repetitive speech, and a score on symbolic activities indicating lack of imaginative play or engagement in repetitive symbolic activities only. Inter‐rater agreement on reaching the threshold for the presence of the triad of impairments was 76–79% (see Perry & Felce 2005; Felce et al. 2009).</p> <hd id="AN0084622605-5">Analysis</hd> <p>Multivariate linear regression was the main analytical method, but other analyses were also undertaken to confirm or amplify findings. An initial analysis exploring the normality of the primary dependent variable, total ABC score, found that the distribution significantly departed from normality (Kolmogorov‐Smirnov statistic = 0.126, P < 0.0001). A square root transformation improved fit, although there remained some deviation from normality in terms of a greater than expected frequency of zero scores (Kolmogorov‐Smirnov statistic = 0.037, P < 0.05). In addition, analyses were undertaken to explore the extent of correlation between the potential risk markers: age, gender, ABS score and presence of the triad of impairments. Gender was not significantly correlated with age, ABS score or presence of the triad of impairments and nor was age with ABS score (absolute value of all r < 0.05, all P > 0.25). However, presence of the triad of impairments was significantly inversely associated with ABS score (r = −0.51, P < 0.0001) and age (r = −0.07, P < 0.05).</p> <p>Variables were entered into a multivariate linear regression, with the square root transformation of total ABC score as the dependent variable. Age and gender were entered in Block 1, presence of the triad of social impairments in Block 2, total ABS score in Block 3 and a term representing the interaction between the presence of the triad of impairments and total ABS score in Block 4. The latter term was created by representing the presence and absence of the triad of impairments as +0.5 and −0.5 respectively and multiplying these figures by standardised total ABS scores (i.e. the contributing variables were centred before creating the interaction term as recommended by Aiken & West 1991). Tests were undertaken to check conformity to assumptions. Errors were independent (Durbin‐Watson statistic = 1.94) and normally distributed (Kolmogorov‐Smirnov statistic = 0.029, P = 0.11). All variance inflation factors were between 1.00 and 1.58, indicating that multicollinearity was within acceptable bounds. A plot of the standardised residuals against standardised predicted values was a random array, indicating that assumptions of linearity and homoscedasticity were met.</p> <p>As the interaction between total ABS scores and the triad of impairments was significant, a graphical analysis was undertaken to explore the nature of the effect using the method described by Aiken & West (1991). In addition, the sample was divided into two groups, one with the triad of impairments (n = 282) and the other without the triad of impairments (n = 536). Kolmogorov‐Smirnov tests showed that the square root transformation of ABC total score was normally distributed in both cases (0.04, P = 0.20; 0.04, P = 0.08 respectively). Variables were entered into a separate multivariate linear regression for each group, with the square root transformation of total ABC score as the dependent variable, age and gender entered in Block 1 and total ABS score in Block 2. In addition, non‐parametric Spearman rank correlations between the ABC domain scores and age, gender and total ABS scores were calculated for each group.</p> <p>As the correlation between the presence of the triad of impairments and total ABS score was reasonably substantial, a confirmatory non‐parametric analysis was undertaken to check the potential influence of the former on ABC total score. Subgroups of participants with and without the triad of impairments were selected that were well matched on ABS scores and age. In order to create subgroups which were similar on ABS scores, the database was ordered by ascending ABS score and, for each person with the triad of impairments present, the adjacent person without the triad was selected as a match. This could not be done for all people with the triad as there were more people with low ABS scores with the triad than without the triad. The initial subgroup selection was then slightly adjusted to achieve similar age as well as ABS score distributions. Both of these selection procedures were undertaken without reference to level of challenging behaviour. ABC total and domain scores were then compared using non‐parametric Mann–Whitney U‐tests.</p> <hd id="AN0084622605-6">Results</hd> <p>The regression analysis found that, in descending order of their standardised coefficients, presence of the triad of impairments, total ABS scores, the interaction between total ABS scores and the triad, and age significantly and independently contributed to the prediction of challenging behaviour (see Table 1). Gender was not significant. Collectively, these variables explained 25% of the variance in ABC scores. Higher ABC scores were associated with the presence of the triad of impairments, lower total ABS scores, lower age and the interaction between total ABS scores and presence of the triad. Figure 1 shows that presence/absence of the triad of impairments moderated the effect of total ABS score on ABC total score. There is an inverse relationship between ABS and ABC scores in the absence of the triad of impairments. However, this is virtually removed when the triad was present (i.e. predicted ABC total scores are similarly high irrespective of total ABS score). Moreover, predicted ABC total scores are higher when the triad of impairments was present, even with high total ABS scores, than when the triad of impairments was absent, even with low total ABS scores.</p> <p>1 Multiple linear regression coefficients and model summaries for potential predictors of the square root of Aberrant Behavior Checklist total scores for the full sample *</p> <p> <ephtml> <table><tr><th /><th>Beta</th><th>P</th></tr><tr><td>Block 1</td><td /><td /></tr><tr><td> Age</td><td>−0.14</td><td>0.000</td></tr><tr><td> Gender</td><td>−0.02</td><td>0.557</td></tr><tr><td> R<sup>2</sup> =0.02, Adj R<sup>2</sup> = 0.02, F<sub>2,815</sub> = 7.66, P = 0.001</td></tr><tr><td>Blocks 1 & 2</td><td /><td /></tr><tr><td> Age</td><td>−0.11</td><td>0.001</td></tr><tr><td> Gender</td><td>−0.02</td><td>0.447</td></tr><tr><td> Triad of social impairments</td><td>0.41</td><td>0.000</td></tr><tr><td> R<sup>2</sup> = 0.19, Adj R<sup>2</sup> = 0.19, F<sub>3,814</sub> = 63.18, P = 0.000, ΔR<sup>2</sup> = 0.17, ΔF<sub>1,814</sub> = 171.03, P = 0.000</td></tr><tr><td>Blocks 1–3</td><td /><td /></tr><tr><td> Age</td><td>−0.12</td><td>0.000</td></tr><tr><td> Gender</td><td>−0.02</td><td>0.605</td></tr><tr><td> Triad of social impairments</td><td>0.29</td><td>0.000</td></tr><tr><td> ABS score</td><td>−0.24</td><td>0.000</td></tr><tr><td> R<sup>2</sup> = 0.23, Adj R<sup>2</sup> =0.23, F<sub>4,813</sub> = 61.11, P = 0.000, ΔR<sup>2</sup> = 0.04, ΔF<sub>1,813</sub> = 44.71, P = 0.000</td></tr><tr><td>Blocks 1–4</td><td /><td /></tr><tr><td> Age</td><td>−0.12</td><td>0.000</td></tr><tr><td> Gender</td><td>−0.01</td><td>0.660</td></tr><tr><td> Triad of social impairments</td><td>0.34</td><td>0.000</td></tr><tr><td> ABS score</td><td>−0.19</td><td>0.000</td></tr><tr><td> ABS × triad interaction</td><td>0.13</td><td>0.000</td></tr><tr><td> R<sup>2</sup> = 0.25, Adj R<sup>2</sup> =0.24, F<sub>5,812</sub> = 52.97, P = 0.000, ΔR<sup>2</sup> = 0.02, ΔF<sub>1,812</sub> = 15.93, P = 0.000</td></tr></table> </ephtml> </p> <p>1 ΔR2 = change in R2, ΔF = F‐test of significance for the change in R2.</p> <p>2 ABS, Adaptive Behavior Scale.</p> <p>The above interpretation of the moderated effect is confirmed by the results of the separate regressions for those with and without the triad of impairments shown in Table 2. Both show younger age to have a small significant impact on ABC scores, but the ABS term is only significant in relation to those without the triad of impairments. Within the 282 participants with the triad of impairments, non‐parametric bivariate correlations showed that age was significantly inversely associated with Irritability domain scores (r<subs>s</subs> = −0.20, P < 0.005) and Hyperactivity domain scores (r<subs>s</subs> = −0.17, P < 0.005) and ABS scores were significantly inversely associated with Stereotypy domain scores (r<subs>s</subs> = −0.16, P < 0.01) and positively associated with Inappropriate Speech domain scores (r<subs>s</subs> = 0.42, P < 0.001). Within the 536 participants without the triad of impairments, non‐parametric bivariate correlations showed that age was significantly inversely associated with Lethargy (r<subs>s</subs> = −0.11, P < 0.05), Hyperactivity (r<subs>s</subs> = −0.10, P < 0.05) and Inappropriate Speech (r<subs>s</subs> = −0.12, P < 0.01) domain scores and ABS scores were inversely significantly associated with all domain scores (Irritability r<subs>s</subs> = −0.21, P < 0.001; Lethargy r<subs>s</subs> = −0.27, P < 0.001; Stereotypy r<subs>s</subs> = −0.31, P < 0.001; Hyperactivity r<subs>s</subs> = −0.28, P < 0.001; Inappropriate Speech r<subs>s</subs> = −0.10, P < 0.05).</p> <p>2 Multiple linear regression coefficients and model summaries for potential predictors of the square root of Aberrant Behavior Checklist total scores for the sample divided into those with ( n  = 282) and without the triad of impairments ( n  = 536) *</p> <p> <ephtml> <table><tr><th /><th>Beta</th><th>P</th></tr><tr><td>Triad of impairments present</td><td /><td /></tr><tr><td> Block 1</td><td /><td /></tr><tr><td>  Age</td><td>−0.16</td><td>0.008</td></tr><tr><td>  Gender</td><td>0.05</td><td>0.434</td></tr><tr><td>  R<sup>2</sup> = 0.03, Adj R<sup>2</sup> = 0.02, F<sub>2,279</sub> = 4.07, P = 0.018</td></tr><tr><td> Blocks 1 & 2</td><td /><td /></tr><tr><td>  Age</td><td>−0.16</td><td>0.007</td></tr><tr><td>  Gender</td><td>0.05</td><td>0.432</td></tr><tr><td>  ABS score</td><td>−0.03</td><td>0.585</td></tr><tr><td>  R<sup>2</sup> = 0.03, Adj R<sup>2</sup> = 0.02, F<sub>3,278</sub> = 2.81, P = 0.040, ΔR<sup>2</sup> = 0.00, ΔF<sub>1,278</sub> = 0.30, P = 0.585</td></tr><tr><td>Triad of impairments absent</td><td /><td /></tr><tr><td> Block 1</td><td /><td /></tr><tr><td>  Age</td><td>−0.09</td><td>0.030</td></tr><tr><td>  Gender</td><td>−0.07</td><td>0.134</td></tr><tr><td>  R<sup>2</sup> = 0.01, Adj R<sup>2</sup> = 0.01, F<sub>2,533</sub> = 3.39, P = 0.034</td></tr><tr><td> Blocks 1 & 2</td><td /><td /></tr><tr><td>  Age</td><td>−0.12</td><td>0.003</td></tr><tr><td>  Gender</td><td>−0.05</td><td>0.252</td></tr><tr><td>  ABS score</td><td>−0.32</td><td>0.000</td></tr><tr><td>  R<sup>2</sup> = 0.11, Adj R<sup>2</sup> = 0.11, F<sub>3,532</sub> = 22.69, P = 0.000, ΔR<sup>2</sup> = 0.10, ΔF<sub>1,532</sub> = 60.54, P = 0.000</td></tr></table> </ephtml> </p> <ulist> <item>3 ΔR2 = change in R2, ΔF = F test of significance for the change in R2.</item> <item>4 ABS, Adaptive Behavior Scale.</item> </ulist> <p>The ages, gender distributions and ABS scores of the two subgroups created to explore the relationship of the triad of impairments and ABC scores non‐parametrically are given in Table 3. Table 4 shows median total and domain scores on the ABC for the two subgroups, with associated ranges, and the significance of the difference in distribution between them. All differences were found to be highly significant other than that for the Inappropriate Speech domain.</p> <p>3 Ages, gender distributions and Adaptive Behavior Scale (ABS) scores of the two subgroups with and without the triad of impairments</p> <p> <ephtml> <table><tr><th>Subgroup</th><th>Mean age (years) (range, SD)</th><th>Gender (% male)</th><th>Mean ABS score (range, SD)</th></tr><tr><td>Triad of impairments present (n = 189)</td><td>44.7 (19–86, 13.7)</td><td>54.5</td><td>140.4 (21–273, 53.5)</td></tr><tr><td>Triad of impairments absent (n = 189)</td><td>44.8 (18–82, 14.7)</td><td>54.0</td><td>140.5 (25–273, 53.5)</td></tr></table> </ephtml> </p> <p>4 Median total Aberrant Behavior Checklist scores and domain scores, with ranges, for the two subgroups with and without the triad of impairments</p> <p> <ephtml> <table><tr><th>Measure of challenging behaviour</th><th>Triad of impairments present (n = 189)</th><th>Triad of impairments absent (n = 189)</th><th>Significance of difference (Mann–Whitney U‐test)</th></tr><tr><td>Median Total ABC scores (range)</td><td>40 (0–131)</td><td>22 (0–105)</td><td>Z = −5.48, P < 0.001</td></tr><tr><td>Median Irritability domain scores (range)</td><td>10 (0–37)</td><td>6 (0–36)</td><td>Z = −3.58, P < 0.001</td></tr><tr><td>Median Lethargy domain scores (range)</td><td>11 (0–39)</td><td>4 (0–32)</td><td>Z = −6.47, P < 0.001</td></tr><tr><td>Median Stereotypy domain scores (range)</td><td>3 (0–20)</td><td>1 (0–18)</td><td>Z = −4.67, P < 0.001</td></tr><tr><td>Median Hyperactivity domain scores (range)</td><td>9 (0–49)</td><td>6 (0–36)</td><td>Z = −3.39, P < 0.005</td></tr><tr><td>Median Inappropriate Speech domain scores (range)</td><td>2 (0–12)</td><td>2 (0–12)</td><td>Z = −1.46, P = 0.144</td></tr></table> </ephtml> </p> <hd id="AN0084622605-7">Discussion</hd> <p>In this study, we investigated how age, gender, level of adaptive behaviour and the presence of the triad of impairments characteristic of autistic spectrum disorder might be related independently to level of challenging behaviour (i.e. ABC total scores) and to different categories of challenging behaviour (i.e. ABC domain scores). Gender did not appear to influence level of challenging behaviour. Age was inversely related, suggesting higher levels of challenging behaviour among the younger adults in the sample. Presence of the triad of impairments was associated with overall level of challenging behaviour and all categories other than Inappropriate Speech. Level of challenging behaviour was also associated with lower total ABS scores, although this association was moderated by the presence or absence of the triad of impairments. Among participants with the triad of impairments, only age was significantly associated with overall level of challenging behaviour, inversely so. The ABS term was non‐significant. Specifically, increased Irritability and Hyperactivity were associated with lower age, while increased Stereotypy was associated with lower ABS scores. Inappropriate Speech was associated with higher ABS scores. Among participants without the triad of impairments, increased overall level of challenging behaviour was associated with younger age and lower ABS scores. Indeed, age was inversely associated with three of the five domain scores (Lethargy, Hyperactivity and Inappropriate Speech) and ABS with all five domain scores.</p> <p>As a cross‐sectional investigation, the present study can only highlight potential factors that might give rise to challenging behaviour. It is important to bear in mind that there may be more fundamental causation, such as particular genotypes, which underpins the correlations described here, either between the triad of impairments and challenging behaviour or between low adaptive behaviour and challenging behaviour (see Dykens 2000). Moreover, repetitive stereotyped behaviour is part of the triad of impairments and a form of challenging behaviour, the presence of which contributes to higher ABC scores. Hence, an association between the presence of the triad of impairments and the overall level of challenging behaviour might be expected. In order to control for this partial tautology, the analysis was repeated with a square root transformation of the total ABC score minus the stereotypy domain score as the outcome. Similar results were found in every respect.</p> <p>In addition, diagnostic validity is always a challenge in research such as this. The use of the ABS to characterise degree of disability is considered a strength as it is a fine‐grain assessment which, although not reflecting severity of ID directly, is a measure of the functional limitations which accompany ID. The sections of the DAS used to assess the triad of impairments are well established for this purpose. However, how accurately one can relate the presence of the triad of impairments to a diagnosis of autism is open to question as the validity of the DAS for distinguishing people with autism from those without autism has not been established and its use for this purpose has been superseded by more recent assessment instruments. This paper therefore will only refer to the triad of impairments having been assessed and whether the findings here would be replicated if the assessment of the triad were replaced by a diagnosis of autism requires further research.</p> <p>The use of the ABC to characterise challenging behaviour also has strengths and weaknesses. On the one hand, it is a well established and commonly used measure for this population. Its factor structure has been replicated across different samples with different respondents (e.g. Freund & Reiss 1991). It has stood up to scrutiny in studies investigating the concurrent validity of more recently developed measures (e.g. Rojahn et al. 2003; Mohr et al. 2005) and scores on the Irritability domain were found to correctly classify 72.8% of cases into either a self‐injury or control group (Matson et al. 2008). However, its domain structure does not entirely separate different behavioural forms of interest. In particular, the Irritability domain combines self‐injury, having temper tantrums or yelling/screaming, aggression to others and various items concerned with mood. Such grouping of behavioural forms may obscure association to the extent that indicators of risk relate to defined topographies of challenging behaviour.</p> <p>A further weakness is that the combined database used for this analysis is skewed in favour of adults living in group homes. Currently in Wales, 1.5% of people on local authority ID registers aged 16 years or over live independently, 51.4% in family homes and 47.1% in some form of residential accommodation, whereas residents of group homes comprised 78.7% of the current sample. This is reflected by the fact that although a wide cross section of ages are represented there is a bias towards older adults (61% were aged 40 years or over). However, gender balance was in line with expectation in having a slight male majority, the representation of ABS scores in each decile was good as is demonstrated above and the proportion of the sample (34.5%) assessed as having the triad of impairments was similar to the finding by Morgan et al. (2002) that adults with IDs and autism comprised 30% of all adults with IDs in their total population study.</p> <p>There are reasons therefore that caution should be exercised in relation to the findings reported here until they are replicated by further research with fewer weaknesses. Nonetheless, they are derived from a relatively large sample and have some common ground with the existing literature. The analysis has found a number of strong associations between ABC total score and the presence of the triad of impairments characteristic of autism, low adaptive behaviour and age. The results are consistent with the meta‐analysis undertaken by McClintock et al. (2003) in showing significant relationships between (<reflink idref="bib1" id="ref6">1</reflink>) the presence of autism and both the overall level of challenging behaviour and different categories of challenging behaviour, provided that the triad of impairments can be taken as a sufficiently accurate proxy for autism, and (<reflink idref="bib2" id="ref7">2</reflink>) level of stereotypy and severity of ID as represented by low adaptive behaviour. Findings also replicate those of Holden & Gitlesen (2006), who found that challenging behaviour as a whole was associated with severity of ID, adolescence and young adulthood, and presence of autism, but not gender.</p> <p>However, as stated in the introduction, much existing research has failed to account for the intercorrelation between potential factors conveying risk for challenging behaviour. The findings here suggest that this oversight is important as the presence of the triad of impairments moderated the relationship between severity of disability/low adaptive behaviour and level of challenging behaviour and that the inverse association between challenging behaviour and adaptive behaviour is characteristic only among those without the triad. Totsika et al. (2011) have recently demonstrated that levels of behavioural and emotional problems were greater among children with autism, with and without ID, than among children with ID alone. Again, to the extent that the triad of impairments can be taken as a proxy for autism, the findings with the adult sample here are consistent with this study in that levels of challenging behaviour among those with the triad of impairments did not have a significant adaptive behaviour gradient and were higher when the triad of impairments was present, even with high total ABS scores, than when the triad of impairments was absent, even with low total ABS scores. However, other recent studies cited in the introduction (Tyrer et al. 2006; Melville et al. 2008; Cooper et al. 2009a,b) did not find an association of various forms of challenging behaviour with autism. These conflicting results call for further investigation.</p> <p>In conclusion, this study has shown that it is necessary to control for intercorrelation between potential risk factors for challenging behaviour and to explore how interaction between them might moderate associations. Findings support previous research that challenging behaviour may be elevated among older adolescents and young adults compared with middle‐aged and older adults. It also supports a strong association between challenging behaviour and the triad of impairments. The presence of the triad of impairments was significantly related to level of challenging behaviour overall and to the majority of sub‐domain scores after control for age and level of adaptive behaviour. This was demonstrated by multivariate linear regression and non‐parametric methods. Finally, it supports a strong association between level of adaptive behaviour and level of challenging behaviour and sub‐domain scores but only for adults with IDs without the triad of impairments.</p> <ref id="AN0084622605-8"> <title>References</title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext>Aiken L. S. & West S. G. ( 1991 ) Multiple Regression: Testing and Interpreting Interactions. 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( 1988 ) The continuum of autistic characteristics. In: Diagnosis and Assessment in Autism (eds E. Schopler & G. B. Mesibov ), pp. 91 – 110. Plenum Press, New York. </bibtext> </blist> <blist> <bibl id="bib44" type="bt">44</bibl> <bibtext>Wing L. & Gould J. ( 1979 ) Severe impairments of social interaction and associated abnormalities in children: epidemiology and classification. Journal of Autism and Developmental Disorders 9, 11 – 29. </bibtext> </blist> </ref> <p>Graph: 1 Illustration of the effect of the interaction between total Adaptive Behavior Scale (ABS) score and the triad of impairments on the predicted square root of Aberrant Behavior Checklist (ABC) total score. Predicted ABC scores were derived from the regression line with the constant term and the mean level entered for the age and gender terms. Low ABS was one SD below the mean. High ABS was one SD above the mean. Triad Present = 1 and Triad Absent = 0. The ABS–triad interaction term, being calculated from standardised scores in the case of the ABS and scores centred as +0.5 and −0.5 in the case of the Triad, was represented by the coefficient multiplied by either +0.5 (for High ABS and Triad Present or Low ABS and Triad Absent) or −0.5 (for High ABS and Triad Absent or Low ABS and Triad Present).</p> <p>Graph: image%5fn/jir1524%5ff1.gif</p> <aug> <p>By D. Felce and M. Kerr</p> </aug>
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  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 11
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2013
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Autism%22">Autism</searchLink><br /><searchLink fieldCode="DE" term="%22Pervasive+Developmental+Disorders%22">Pervasive Developmental Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22At+Risk+Persons%22">At Risk Persons</searchLink><br /><searchLink fieldCode="DE" term="%22Behavior+Problems%22">Behavior Problems</searchLink><br /><searchLink fieldCode="DE" term="%22Adults%22">Adults</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Retardation%22">Mental Retardation</searchLink><br /><searchLink fieldCode="DE" term="%22Disability+Identification%22">Disability Identification</searchLink><br /><searchLink fieldCode="DE" term="%22Age+Differences%22">Age Differences</searchLink><br /><searchLink fieldCode="DE" term="%22Gender+Differences%22">Gender Differences</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Group+Homes%22">Group Homes</searchLink><br /><searchLink fieldCode="DE" term="%22Adjustment+%28to+Environment%29%22">Adjustment (to Environment)</searchLink><br /><searchLink fieldCode="DE" term="%22Interaction%22">Interaction</searchLink><br /><searchLink fieldCode="DE" term="%22Speech+Communication%22">Speech Communication</searchLink><br /><searchLink fieldCode="DE" term="%22Hyperactivity%22">Hyperactivity</searchLink><br /><searchLink fieldCode="DE" term="%22Symptoms+%28Individual+Disorders%29%22">Symptoms (Individual Disorders)</searchLink><br /><searchLink fieldCode="DE" term="%22Multivariate+Analysis%22">Multivariate Analysis</searchLink><br /><searchLink fieldCode="DE" term="%22Regression+%28Statistics%29%22">Regression (Statistics)</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22United+Kingdom+%28England%29%22">United Kingdom (England)</searchLink><br /><searchLink fieldCode="DE" term="%22United+Kingdom+%28Wales%29%22">United Kingdom (Wales)</searchLink>
– Name: SubjectThesaurus
  Label: Assessment and Survey Identifiers
  Group: Su
  Data: <searchLink fieldCode="SU" term="%22Aberrant+Behavior+Checklist%22">Aberrant Behavior Checklist</searchLink><br /><searchLink fieldCode="SU" term="%22Adaptive+Behavior+Scale%22">Adaptive Behavior Scale</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1111/j.1365-2788.2011.01524.x
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0964-2633
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Background: Identification of possible personal indicators of risk for challenging behaviour has generally been through association in cross-sectional prevalence studies, but few analyses have controlled for intercorrelation between potential risk factors. The aim was to investigate the extent to which gender, age, presence of the triad of impairments characteristic of autism and level of adaptive behaviour were independently associated with level of challenging behaviour among adults with intellectual disabilities. Methods: Five datasets were merged to produce information on challenging behaviour, adaptive behaviour, presence of the triad of impairments, gender and age of 818 adults. Variables were entered into a multivariate linear regression, which also tested the interaction between the presence of the triad of impairments and level of adaptive behaviour. Results: Presence of the triad of impairments, level of adaptive behaviour, their interaction, and age, but not gender, significantly and independently contributed to the prediction of challenging behaviour. Presence/absence of the triad of impairments moderated the effect of adaptive behaviour on challenging behaviour. The inverse relationship found in the absence of the triad of impairments was virtually removed when present. Conclusions: This study has shown that it is necessary to control for intercorrelation between potential risk factors for challenging behaviour and to explore how interaction between them might moderate associations. (Contains 4 tables and 1 figure.)
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: Ref
  Label: Number of References
  Group: RefInfo
  Data: 44
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2014
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1013061
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1013061
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1111/j.1365-2788.2011.01524.x
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 11
        StartPage: 128
    Subjects:
      – SubjectFull: Autism
        Type: general
      – SubjectFull: Pervasive Developmental Disorders
        Type: general
      – SubjectFull: At Risk Persons
        Type: general
      – SubjectFull: Behavior Problems
        Type: general
      – SubjectFull: Adults
        Type: general
      – SubjectFull: Mental Retardation
        Type: general
      – SubjectFull: Disability Identification
        Type: general
      – SubjectFull: Age Differences
        Type: general
      – SubjectFull: Gender Differences
        Type: general
      – SubjectFull: Foreign Countries
        Type: general
      – SubjectFull: Group Homes
        Type: general
      – SubjectFull: Adjustment (to Environment)
        Type: general
      – SubjectFull: Interaction
        Type: general
      – SubjectFull: Speech Communication
        Type: general
      – SubjectFull: Hyperactivity
        Type: general
      – SubjectFull: Symptoms (Individual Disorders)
        Type: general
      – SubjectFull: Multivariate Analysis
        Type: general
      – SubjectFull: Regression (Statistics)
        Type: general
      – SubjectFull: United Kingdom (England)
        Type: general
      – SubjectFull: United Kingdom (Wales)
        Type: general
      – SubjectFull: Aberrant Behavior Checklist
        Type: general
      – SubjectFull: Adaptive Behavior Scale
        Type: general
    Titles:
      – TitleFull: Investigating Low Adaptive Behaviour and Presence of the Triad of Impairments Characteristic of Autistic Spectrum Disorder as Indicators of Risk for Challenging Behaviour among Adults with Intellectual Disabilities
        Type: main
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      – PersonEntity:
          Name:
            NameFull: Felce, D.
      – PersonEntity:
          Name:
            NameFull: Kerr, M.
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          Dates:
            – D: 01
              M: 02
              Type: published
              Y: 2013
          Identifiers:
            – Type: issn-print
              Value: 0964-2633
          Numbering:
            – Type: volume
              Value: 57
            – Type: issue
              Value: 2
          Titles:
            – TitleFull: Journal of Intellectual Disability Research
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