Oliver, C., Petty, J., Ruddick, L. and Bacarese- Hamilton, M.eprints.bham.ac.uk/1090/1/Oliver_et_al_in_press_Repetitve_behavior... · Oliver, C., Petty, J., Ruddick, L. and Bacarese-Hamilton,

Repetitive, self-injurious and aggressive behavior 1

The association between repetitive, self-injurious and aggressive behavior in children with severe

intellectual disability

Oliver, C., Petty, J., Ruddick, L. and Bacarese-

Hamilton, M.

Cerebra Centre for Neurodevelopmental Disorders,

School of Psychology,

University of Birmingham

Please use this reference when citing this work:

Oliver, C., Petty, J., Ruddick, L. and Bacarese-Hamilton, M. (In press). The association between

repetitive, self-injurious and aggressive behavior in children with severe intellectual disability. Journal

of Autism and Developmental Disorders DOI: 10.1007/s10803-011-1320-z

The Cerebra Centre for Neurodevelopmental Disorders, School of Psychology, University of Birmingham, Edgbaston, Birmingham, B15 2TT Website: www.cndd.Bham.ac.uk E-mail: [email protected]


Abstract

We evaluated the independent association between adaptive behavior, communication

and repetitive or ritualistic behaviors. and self-injury, aggression and destructive

behavior to identify potential early risk markers for challenging behaviors. Data were

collected for 943 children (4 to 18 years, M= 10.88) with severe intellectual

disabilities. Odds ratio analyses revealed that these characteristics generated risk

indices ranging from 2 to 31 for the presence and severity of challenging behaviors.

Logistic regressions revealed that high frequency repetitive or ritualistic behavior was

associated with a 16 times greater risk of severe self-injury and a 12 times greater risk

of showing two or more severe challenging behaviors. High frequency repetitive or

ritualistic behaviors independently predict challenging behavior and have the potential

to be early risk markers for self-injury and aggression of clinical significance.

Keywords: stereotyped behavior, repetitive behavior, self-injury, aggression,

intellectual disability, autism spectrum disorder, prevalence


The association between repetitive, self-injurious and aggressive behavior in

children with severe intellectual disability.

Approximately 40% of children and adults with severe intellectual disability show

challenging behaviors, such as self-injury and aggression (Harris, 1993; Kebbon &

Windahl, 1986; Rojahn, Borthwick-Duffy & Jacobson, 1993). The prevalence and

severity of self-injurious and aggressive behaviors rises with age into the third decade

and self-injury has been shown to persist over decades (Borthwick-Duffy, 1994;

Oliver, Murphy & Corbett, 1987; Taylor, Oliver and Murphy, 2011; Totsika,

Toogood, Hastings & Lewis, 2008). When severe, these behaviors are associated with

family, educational and residential placement breakdown and can result in costly ‘out

of area’ specialised residential placements (Hallam & Trieman, 2001; Knapp, Comas-

Herrera, Astin, Beecham, & Pendaries, 2005; Pritchard and Roy 2006).

Theoretical models and empirical research identify a role for operant learning in the

increasing severity and maintenance of self-injurious and aggressive behaviors

(Oliver, 1995; Oliver, Hall & Murphy, 2005). Meta-analytic studies reveal that the

most effective interventions are those based on applied behavior analysis (Harvey,

Boer, Meyer & Evans 2009; Kahng, Iwata & Lewin, 2002; Meyer & Evans, 2006)

with limited evidence that psychopharmacological interventions are effective (Singh

et al., 2005; Tyrer et al., 2009) despite their widespread use (Molyneux, Emerson &

Caine, 1999; Robertson et al., 2000). However, behavioral interventions are labour

and resource intensive for severe challenging behavior and consequently rarely

available (Oliver et al., 1987; Roberston et al., 2005).


In combination these observations suggest that early intervention might be an efficient

strategy (Oliver 1995; Richman, 2008; Symons, Sperry, Dropik & Bodfish, 2005),

particularly if young children at the highest risk for the development of challenging

behavior can be identified and targeted. There are a number of person and

environment characteristics that appear to predate the development of more severe

challenging behavior and might therefore be considered to be risk markers. These

include a greater degree of intellectual disability, the presence of social impairment or

specific genetic syndromes, associations between social contact and behavior that are

consistent with operant theories of the maintenance of behavior, and the presence of

repetitive behavior (Arron, Oliver, Berg, Moss & Burbidge, 2011; Baghdadli, Pascal,

Grisi, & Aussilloux, 2003; McClintock, Hall, & Oliver, 2003; Murphy et al., 2005;

Murphy, Healy & Leader, 2009; Saloviita, 2000).

The association between repetitive and challenging behaviors is of interest for a

number of reasons. First, in Guess and Carr’s (1991) model it is proposed that self-

injury evolves from stereotyped movements (see Oliver, 1993) and empirical

evidence comes from observational studies employed within longitudinal and cross

sectional designs (Hall, Oliver & Murphy, 2001; Hall, Thorns & Oliver, 2003; Oliver

et al., 2005; Petty, Allen & Oliver, 2009). Second, an association between repetitive

behaviors, self-injury, and aggression is evident within a number of syndromes, such

as Fragile X, Cornelia de Lange, and Prader-Willi, in which self-injury is prominent

(Sloneem et al., 2009; Arron, et al., 2011). This suggests that this association might be

common across different causes of intellectual disability. Third, in Turner’s

theoretical model of repetitive behavior, it is suggested that compromised behavioral

inhibition is implicated in the initiation of episodes of stereotyped behavior and the


inability to terminate episodes of this type of behavior in the absence of external

direction (Turner, 1999). Repetitive behaviour is therefore construed as influenced by

an ability to regulate behaviour. If this theory is correct then it might be predicted that

compromised behavioral inhibition, as evidenced by the presence of repetitive

behaviors, will be associated with greater severity of behaviors, such as self-injury

and aggression, as the problems of initiation and termination will be evident for these

behaviors as well as repetitive behaviors.

There is recent evidence that both repetitive behaviors and other behaviors associated

with compromised behavioral inhibition, such as impulsivity, are associated with both

the presence and severity of challenging behaviors in people with intellectual

disability (Cooper, Smiley, Allan et al., 2009; Cooper, Smiley, Jackson et al., 2009;

Petty and Oliver, 2005; Hyman, Oliver & Hall, 2002). Bradley, Summers, Wood &

Bryson (2004) described differences in impulse control, stereotyped behavior, and

self-injury in a small study comparing adolescents and young adults with severe

intellectual disability with and without autism. The two groups (N=12) were matched

for age, gender, and VABS scores (Sparrow, Balla & Cicchetti, 1984; subscales

assessed communication, socialisation, daily living skills and adaptive behaviour).

The autism group showed higher levels of self-injury and stereotyped behavior and

poorer impulse control. These observations suggest that the presence of repetitive

behaviors might be a risk marker for both the presence and severity of challenging

behavior by virtue of the underlying compromised behavioral inhibition and warrants

further investigation in a larger sample.


To date, evaluation of the association between repetitive behavior and challenging

behaviors in the highest risk group for challenging behavior, those with more severe

intellectual disability, is frequently confounded in analyses. This is illustrated in the

meta-analytic study of McClintock et al., (2003), in which they found a significant

association between both a more severe degree of intellectual disability and autism

spectrum disorders and the prevalence of self-injury, stereotypy, and destruction of

property. Additionally, there was a significant association between poor

communication and the prevalence of self-injurious behavior. However, a higher

prevalence of autism spectrum disorder is evident in those with more severe

intellectual disability and compromised communication is associated with both severe

intellectual disability and autism spectrum disorder. These associations indicate the

need to identify independent relationships between potential risk markers and

challenging behavior.

In this study we examine the relationship between repetitive and ritualistic behavior

and the presence and severity of different forms of challenging behavior in different

age groups of children with severe intellectual disability whilst controlling for

potentially confounding variables of a greater degree of intellectual disability and

compromised expressive communication. Given the potential role of compromised

behavioral control in repetitive behavior we predict that greater severity of

challenging behavior will be associated with the presence of repetitive and ritualistic

behavior and that this association will be robust when other potentially confounding

variables are controlled.

Methods


Participants

1096 children attending 17 special schools for children with severe intellectual

disabilities were surveyed within one city. Data were collected on 970 (89%) children.

Children below 4 years of age (N= 17) and over 19 years of age (N= 10) were removed

from the sample due to low numbers, leaving a sample of 943 children. The age range

was 4 years 0 months to 18 years 11 months (M= 10.88, SD= 3.87). Sixty-two percent

(N=589) of participants were male. Data from the Self Help and Behavior rating scale

(see Measures) indicated that 35% of the children were completely or partly immobile

without aids, 48% were completely or partly incontinent, and that the proportions of

the sample with a visual or hearing impairment were 18.8% and 10.9% respectively.

These data also showed that 38% of the children were unable to feed themselves

without help, 58.4% were unable to wash themselves without help and 62.3% were

unable to dress themselves without help. In terms of literacy, 89.5% were unable to

read more than ‘a little’, 92.3% were unable to write more than ‘a little’ and 91% had

little or no understanding of numbers.

Measures

The Self-Help and Behaviour rating scale (an adapted version of the Wessex

Behaviour Scale, Kushlick, Blunden & Cox, 1973) was divided into two sections: self-

help skills and general abilities, and behavior and emotional difficulties. The original

instrument contains nine subscales: general details (e.g., date of birth), incapacities

(e.g., continence, mobility and literacy), speech clarity; behaviour problems

(aggression, destructive behaviour, over-activity, attention seeking and self-injury),

present employment; education and/or training, parole, admission (regarding who

accompanied the individual at admission), and legal status at admission. All items were

scored on a three-point scale with 1 indicating severe incapacity, 2 mild incapacity,

and 3 no incapacity. Two scales can be derived from the data: the Social and Physical

Incapacity (SPI) scale based on ratings of continence, mobility, and behaviour


problems; and the Speech, Self Help and Literacy (SSL) scale based on ratings of an

individual’s ability to speak, wash, dress, and feed themselves and to read, write, and

count. The self-help skills and general abilities section was an amalgamation of the

incapacities and speech subscales of the original Wessex Scale. The self-help and

general abilities section contained twenty items covering mobility, washing, dressing

and feeding, sleep, continence, literacy and numeracy, speech, vision and hearing

impairment, daytime supervision and attention and concentration. All twenty items

were scored on a three-point scale (1 referring to severe impairment, 2 some

impairment, and 3 no impairment).

Palmer and Jenkins (1982) reported inter-rater reliability data for the original Wessex

scale across both adult and child populations and residential and non-residential

settings, and reported a mean Kappa value for overall classification of .62 (range .54

to .72). Kappa values for item level reliability ranged from .33 to .89 (mean .54).

Palmer and Jenkins (1982) suggested reliability for the scale was ‘modest’ but that

the scale had use in large-scale surveys due its quick and easy format.

Five items regarding aggression, destructive behavior, hyperactivity, repetitive and

ritualistic behavior, and self-injurious behavior were taken from the original Wessex

scale to comprise the behaviour and emotional difficulties section. Items were scored

on a five-point frequency scale (1, never to 5 very often [daily or more often]). Items

were also scored on a five-point management difficulty scale (1 not difficult to

manage to 5 seriously difficult to manage). Teachers completed the adapted Self-

Help and Behaviour rating scale for every child in their class, and in 15.5% (N=146)

of cases a Learning Support Assistant also independently filled out the scale to

provide inter-rater reliability data. Reliability between informants was sufficient

(mean Kappa value = .76, range .67-.82).

Data analysis


An index of comparative degree of deficit in adaptive behavior was created by

combining the three self-help items (feeding, washing, and dressing) and the three

literacy items (reading, writing, and numeracy) from the Self-Help and Behaviour

scale. There were significant levels of positive correlation between all six items

(mean r =.65, range .50 to .86, p<.01). The sample was split into two age bands: 4

years to 10 years 11 months (N= 522) and 11 years to 18 years 11 months (N= 421).

In order to allow odds ratios to be calculated across these age groups, a median split

of the adaptive behavior variable was used to create ‘more severe deficit in adaptive

behavior’ and ‘less severe deficit in adaptive behavior’ groups. In order to reduce the

possibility that the younger age group would be scored as having a more severe

deficit in adaptive behavior (by virtue of being younger and development of adaptive

behaviour is correlated with age in typical development) the sample was split into

three age bands for the purpose of creating this variable. This ensured that the

youngest children in the sample were not being compared directly with those that

were chronologically older. Chi-squared comparisons of levels of continence,

mobility, sensory impairments, self help skills, and literacy skills across the two

adaptive behavior groups were conducted. The validity of the ‘more severe’ and ‘less

severe’ deficit in adaptive behavior groups was indicated by the significant

differences between the groups across all items (p<.001 for all chi squared

comparisons).

In order to evaluate the association between the absence of speech and the presence

and severity of self-injurious, aggressive, destructive, and multiple behaviours, it was

necessary to create a dichotomised index of speech, by dividing scores on the speech

item of the Self Help and Behaviour rating scale into two groups. Individuals scoring

1 were deemed to represent a ‘no speech’ group compared to those scoring 2 or 3,


(reflecting odd words or sentence speech) who were deemed to reflect a ‘speech’

group.

Frequency data for challenging behaviors were collapsed into ‘never’ (score of 1),

‘moderate’ (score of 2 or 3) and ‘highly frequent’ (score of 4 or 5) and also

‘presence’ (score of 2 or above) and ‘absence’ (score of 1). A series of Mann

Whitney non parametric tests were carried out using ‘moderate’ or ‘highly frequent’

behavior as the independent variable and the teacher rating of management difficulty

as the dependent variable. There were significant differences in reported

management difficulty between moderate and highly frequent groups for all

behaviors, demonstrating that highly frequent challenging behavior (scores of 4 or 5,

reflecting behavior occurring at least 5 times per month) presents a significantly

higher degree of management difficulty than low frequency behavior. We will

therefore use the term ‘severe’ challenging behavior throughout to refer to highly

frequent behavior.

Due to the number of analyses carried out, the alpha level was corrected to p<.01 for

all tests.

Results

With regard to the presence of challenging behavior, 153 (17%) of the total sample

showed self-injurious behavior, 356 (39.5%) showed aggressive behavior and 267

(29.6%) showed destructive behavior. 60 (6.6%) participants showed two or three

topographies of challenging behavior at a severe level.


In order to evaluate the risk for self-injurious, aggressive, destructive, and multiple

behaviors associated with a more severe deficit in adaptive behavior, high frequency

repetitive or ritualistic behavior, and the absence of speech, odds ratios were

calculated across the potential risk markers both individually and in combination

(e.g., those with a more severe deficit and high frequency repetitive behavior

compared to all other participants). To investigate potential differences in risk with

increasing age, odds ratios were calculated for the total sample, 4 years to 10 years

11 months, and 11 years to 18 years 11 months age groups. Results of the odds ratio

calculations can be seen in Figure 1. In order to assess the significance of the odds

ratio values, 99% confidence intervals were calculated and the values can be seen as

error bars in Figure 1. Odds ratio values were deemed significant at the p<.01 level if

both upper and lower confidence interval values were above one as is typical for

odds ratio and relative risk analyses (e.g. McClintock et al., 2003).

+++++++Insert Figure 1 here ++++++

A more severe deficit in adaptive behavior was significantly associated with the

presence of self-injury in all groups, with severe aggression in the total sample, with

the presence of destructive behavior in the 11 to 18 year old group, and with severe

destructive behavior in all groups. When assessed in combination with the other risk

marker variables, odds ratio values increased in most (over 75%) cases. For example,

when combined with absence of speech and repetitive and ritualistic behaviors

individually, odds ratio values increased in 62% and 86% of cases respectively,

suggesting that more severe deficit in adaptive behavior was not a particularly


influential risk marker within this sample as the presence of other variables usually

lead to an increase in risk.

The presence of high frequency repetitive or ritualistic behavior was significantly

associated with both the presence and severity of self-injurious, aggressive and

destructive behaviors and the presence of two or more severe challenging behaviors

across the total sample and both age groups. When the influence of the presence of

high frequency repetitive or ritualistic behavior was assessed in combination with the

other risk markers, the odds ratio value decreased in 80% of cases. In all other cases

the odds ratio value stayed the same suggesting that high frequency repetitive or

ritualistic behavior is a robust risk marker as the addition of other variables generally

reduces its influence.

The absence of speech was significantly associated with the presence and severity of

self-injury in the total sample and the 11 to 18 year old group and with severe

destructive behavior in the 11 to 18 year old group. When the absence of speech was

assessed in combination with the other risk markers the odds ratio values increased in

almost 70% of cases suggesting that the absence of speech is not a particularly

influential risk marker as the addition of other variables generally increases odd ratio

values relative to the influence of absence of speech alone.

In order to assess the individual contribution of these potential risk markers in a more

controlled analysis, a series of forced entry binary logistic regressions (Field, 2000)

were carried out using self-injurious behavior, aggression and destructive behavior,

and two or more severe challenging behaviors as dependent variables and more


severe deficit in adaptive behavior, presence of high frequency repetitive or

ritualistic behavior, and presence of speech as predictors (see Figure 2).

+++++++++ Insert figure 2 here ++++++++++++

All logistic regression models were significant relative to the constant (p<.0001). A

test of the model for the presence of self-injurious behavior correctly classified

70.5% of cases and severe degree of deficit in adaptive behavior and presence of

high frequency repetitive or ritualistic behavior significantly contributed to the

model. Models predicting the presence of aggressive and destructive behaviors

correctly classified 60.9% and 65.1% of cases respectively and the presence of high

frequency repetitive or ritualistic behavior and the presence of speech contributed

significantly to both models. Models predicting severe self-injurious, aggressive and

destructive behavior, and the presence of two or more severe challenging behaviors

correctly classified 76%, 68.5%, 70.7% and 75.6% of cases respectively and in all

cases the presence of high frequency repetitive or ritualistic behavior was the sole

contributor to the model.

Discussion

The influence of more severe deficit in adaptive behavior, high frequency repetitive

or ritualistic behaviors, and presence of speech as risk markers for self-injurious,

aggressive, destructive, and multiple behaviors was examined in a sample of 943

children attending schools for children with severe intellectual disabilities. The

prevalence of self-injurious, aggressive, and destructive behaviors was identified as

17.1%, 39.7% and 29.8% respectively and these rates are comparable to those


reported elsewhere (Emerson et al., 2001; Powell, Bodfish, Parker, Crawford, &

Lewis, 1996).

The key finding of this study is the identification of the presence of high frequency

repetitive or ritualistic behavior as a robust risk marker for self-injurious, aggressive,

destructive, and multiple behaviors. Odds ratio analyses showed that high frequency

repetitive or ritualistic behavior was significantly associated with both the presence

and severity of all behaviors. Assessment of the additive effects of potential risk

markers highlighted that this variable is a robust marker as it was the only variable

for which the odds ratio values decreased with the addition of other variables. A

series of binary logistic regressions allowed an investigation of the contribution of

individual risk markers whilst controlling for the effects of others. This method

confirmed that high frequency repetitive or ritualistic behavior was a robust risk

marker for challenging behavior as it significantly predicted both the presence and

severity of all topographies of behavior when other variables were controlled for.

The finding regarding the presence of challenging behavior is consistent with the

findings of McClintock et al. (2003) who reported that a diagnosis of autism was

significantly associated with a higher prevalence of self-injurious, aggressive, and

destructive behaviors. The finding regarding the severity of challenging behavior is

novel and clearly of both clinical and theoretical importance. A risk marker that

predates challenging behavior and predicts which individuals are most likely to show

more severe challenging behavior is clearly important for clinical services in terms of

intervention strategy and appropriate use of resources.

The finding also suggests that this risk marker may moderate the severity of the

behavior in some way, or reflect an impaired ability to regulate the behavior once it


is established. Turner (1997, 1999) discusses repetitive behavior in individuals with

autism in terms of an indicator of executive dysfunction. She suggests that

individuals may be unable to regulate or inhibit ongoing behavioral responses,

leading to the repetition of often inappropriate responses. This theory provides a way

in which the presence of high frequency repetitive behavior may be associated with

the dysregulation of more severe challenging behavior. Rather than the repetitive

behavior itself causing the increased severity of the challenging behavior, it is more

likely that it is indicative of impaired behavioral inhibition due to some degree of

executive dysfunction. The inability to regulate repetitive behavior may suggest a

general incapacity to regulate behavior, which would similarly explain an increase in

the severity of other behaviors in an individual’s repertoire.

A second key finding of the study was that the variables that predicted the presence

of a behavior were different from those that predicted the severity of the behavior.

Whilst high frequency repetitive or ritualistic behavior was the only variable to

predict severity of behavior, other variables in addition to this predicted the presence

of behavior. The presence of self-injurious behavior was predicted by repetitive or

ritualistic behavior and more severe deficit in adaptive behavior. As discussed above,

the association between repetitive behavior and self-injury is supported by previous

research on self-injury in individuals with and without autism. The association

between more severe intellectual disability and self-injury is well established in the

literature (e.g., Borthwick-Duffy, 1994; McClintock et al., 2003; Murphy et al.,

2009). The odds ratio analyses in the current study showed that an absence of speech

was significantly associated with the presence of self-injury but in the regression

analysis, the presence of speech did not predict self-injurious behavior and failed to


replicate the finding of McClintock et al. (2003) who report an odds ratio of 3.37 for

self-injury in individuals with a deficit in expressive communication. The most likely

explanation for this discrepancy is the fact that in both the current odds ratio analysis

and that of McClintock et al. (2003), the influence of expressive communication was

related to degree of intellectual disability and therefore when degree of disability was

controlled for in the regression analysis, the effect of expressive communication was

not strong enough to be evident.

The presence of both aggressive and destructive behaviors was predicted by the

absence of speech as well as repetitive or ritualistic behavior in the regression

analyses. Whilst the literature regarding communication and self-injury generally

suggests that more severe deficits in communication are associated with a higher

prevalence of behavior, data regarding aggressive and destructive behaviors paint a

rather more complicated picture. Some studies (Bott, Farmer, & Rohde, 1997) have

reported increased rates of behavior associated with lower levels of expressive

communication, whilst others have reported that a less severe deficit in

communication is associated with a higher prevalence of challenging behavior

(Emerson et. al., 2001). Rojahn, Matson, Naglieri and Mayville (2004) calculated

risk ratios for psychiatric conditions given various challenging behaviors and found

that aggressive and destructive behavior represented a risk factor for the presence of

language disorders. However, more severe aggressive behavior did not significantly

elevate the risk for language disorder leading the authors to suggest that it may be

that milder aggressive behavior fulfils a communicative function for individuals

whilst more severe behavior does not. Whilst Rojahn et al. (2004) found that the

presence of less severe behavior was associated with a communication impairment,


the current study found the opposite, that the presence of aggressive and destructive

behavior was associated with less impaired communication. Whilst the current

survey only included children attending schools for children with severe intellectual

disability, Rojahn et al.’s (2004) sample included individuals whose intellectual

disability ranged from mild to profound. It is therefore possible that the contradictory

findings reflect the different ranges of ability in the samples. The fact that other

studies have found a relationship between disability and prevalence of behavior may

simply reflect the comparison of mild disability with more severe disability in these

studies.

A more severe degree of deficit in adaptive behavior did not significantly predict

aggression or destructive behavior, a similar finding to that of McClintock et al.

(2003) and others (e.g., Davidson et al., 1999). This suggests that it may be the more

able children that are showing aggressive and/or destructive behavior and that

perhaps these behaviors require a greater degree of verbal or physical ability to

perform. This also adds support to the finding regarding speech as the presence of

speech may reflect less severe disability. The influence of degree of disability alone

on the prevalence of aggressive and/or destructive behaviour is likely to remain

unclear whilst the populations used in prevalence studies are inconsistent in terms of

the range of disability they represent. Finally, it is notable that the influence of

combined risk markers differed across the age groups. In the younger age group the

combination of the presence of repetitive behavior, absence of speech and

comparatively poorer adaptive behavior was a less strong predictor of presence and

severity of outcome behaviors than for the older group. This suggests that this


combination has greater significance in the aetiology of self-injury, aggression and

destruction of the environment as children become older.

There are several strengths of this study that are worthy of mention. The sample was

very large, and thus more likely to be representative of the base population from

which it was drawn and the sample size also reduces the likelihood of response bias,

as questionnaires were completed for virtually all children in a particular school,

regardless of the presence of challenging behavior. Another strength is that the data

regarding degree of deficit in adaptive behavior and repetitive and ritualistic behavior

was calculated using a relative score, allowing meaningful differentiation of

individuals even within a population of children attending schools for severe

intellectual disabilities. Finally, the main strength of the study is the extension of

McClintock et al.’s (2003) meta-analysis by controlling for the potential confound

between variables.

A limitation of the interpretability of the data is the issue concerning the use of levels

of adaptive behavior and repetitive and ritualistic behaviors in the place of data

regarding degree of intellectual disability and autism respectively. Previous research

has compared mild to moderate disability with severe to profound disability and

provided strong evidence of the association between more severe intellectual

disability and challenging behavior (i.e., Borthwick-Duffy, 1994; Smith et. al.,

1996). The adapted Wessex Behaviour Scale provided information that allowed the

sample to be split into more severe and less severe deficit in adaptive behavior

groups but this did not provide an absolute index of degree of disability, just a


relative score. It was therefore unclear if the effect of disability found previously

would be replicated, as it was possible that children in the less severe deficit group

also had a severe intellectual disability. The results of the logistic regressions showed

that a more severe deficit in adaptive behavior significantly predicted the presence of

self-injury, suggesting that there is still a degree of differentiation possible within the

severe deficit in adaptive behavior range and that degree of adaptive behavior may

still be a useful predictor of challenging behavior even within a group with a

restricted range of abilities. The fact that a more severe deficit in adaptive behavior

predicted self-injury, and therefore replicated McClintock et al.’s (2003) findings,

suggests that the information provided by the adapted Wessex Behavior Scale is a

valid index of relative degree of intellectual disability.

It must also be noted that the current study was not using autism as a risk marker as

McClintock et al. (2003) did, but the presence of behaviors that may be indicative of

an autistic spectrum disorder. Repetitive behavior is one of the three defining

characteristics of autistic spectrum disorder but whilst there is a clear association

between the presence of repetitive behaviors and autism, the current study is not

implying that individuals deemed to show high frequency repetitive behavior

necessarily have an autistic spectrum disorder. Also, whilst a diagnosis of autism

may be more likely in those showing such behavior, the strength of the current

findings using a behavioral measure suggests that a diagnosis of core autism may be

neither necessary nor sufficient to explain the presence of challenging behavior, as

many individuals without such diagnosis will display repetitive and ritualistic

behaviors to some extent. The presence of such behavior in individuals without

autism may explain why some authors (i.e., Emerson et al., 2001; Murphy, Hall,


Oliver, & Kissi-Debra, 1999) reported no significant association between autism and

challenging behavior as many of the individuals in the ‘no autism’ groups might have

been displaying ‘autistic-like’ behaviors. Focusing on the presence of repetitive

behaviors rather than autism itself provides a more valid approach to examining risk

markers for challenging behavior as individuals without a diagnosis of autism but

whose behavior is severe enough to impact on their daily functioning will be

included.

In summary, this study demonstrates a strong association between repetitive

behaviors and behaviors of clinical significance while controlling for potentially

confounding variables. As repetitive behaviors typically predate behaviors of clinical

significance that are severe, we believe the presence of repetitive behaviors should be

investigated as a potential risk marker for the future development of self-injuious

behavior in particular, with implications for targeted early intervention.


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Author Note

Figure Caption Sheet

Figure 1: Odds ratio values for the associations between more severe deficit in

adaptive behaviour, high frequency repetitive / ritualistic behaviour and absence of

speech (individually and in combination) and the presence and severity of self-

injurious, aggressive, destructive and multiple behaviours across the total sample and

two age groups.

Figure 2: Binary logistic regressions predicting the presence and severity of

challenging behaviour from high frequency repetitive / ritualistic behaviour, severe

deficit in adaptive behaviour and presence of speech.



χ2 for model = 72.81** χ

2 for model = 35.77**


2 for model =31.87**


2 for model = 29.84**

Presence of Self-Injurious

Behaviour

High frequency

repetitive / ritualistic

behaviour

Severe deficit in

adaptive behaviour

Presence of speech

Severe level of Self-

Injurious Behaviour

High frequency


behaviour

Severe deficit in

adaptive behaviour

Presence of speech

High frequency


behaviour

Severe deficit in

adaptive behaviour

Presence of speech

Figure 2 Top

Presence of Aggression

Severe level of Aggression

Presence of Destructive

Behaviour Severe level of

Destructive Behaviour

Two or more severe

challenging behaviours

High frequency


behaviour

Severe deficit in

adaptive behaviour

Presence of speech

p= .0001

OR= 6.43

p= .0001

OR= 3.15

p= .26

OR= 1.45

p= .0001

OR= 16.21

p= .43

OR= 1.63

p= .04

OR= .282

p= .0001

OR= 3.64

p= .0001

OR= 4.87

p= .0001

OR= 4.50

p= .0001

OR= 5.97

p= .0001

OR= 11.78

p= .46

OR= 1.14

p= .07

OR= 1.88

p= .0001

OR= 2.54

p= .41

OR= 1.39

p= .03

OR= 1.59 p= .02

OR= 3.15

p= .005

OR= 1.96 p= .22 OR= 1.80

p= .07 OR= 2.72

p= .07

OR= 2.67

χ2 for model = 39.70**

** p<.0001

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