Research in Developmental Disabilities 104 (2020) 103718

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Research in Developmental Disabilities

journal homepage: www.elsevier.com/locate/redevdis

Factors affecting the relationship between adaptive behavior and

T
challenging behaviors in individuals with intellectual disability and
co-occurring disorders
Giulia Balbonia,*, Gessica Rebecchinia, Sandro Eliseib, Marc J. Tasséc
a
University of Perugia, Italy
b
Serafico Institute of Assisi, Research Centre “InVita”, Assisi, PG, Italy
c
The Ohio State University, OH, USA

A R T IC LE I N F O ABS TRA CT

Number of reviews completed is 3 Previous studies have reported an inverse relationship between adaptive behavior and challen-
Keywords: ging behaviors in individuals with ID. However, it is unclear which characteristics might influ-
Adaptive behavior ence this relationship in individuals with ID and co-occurring conditions. We found a positive
Challenging behaviors correlation between adaptive behavior (Vineland-II) and challenging behaviors (Nisonger Child
Intellectual disability Behavior Rating Form) in a study of 105 individuals who presented with mostly severe to pro-
Co-occurring disorders found ID and comorbid physical and mental health conditions. These results might be the con-
Mental health sequence of the individual participant characteristics. Therefore, participants were separated out
Institutional setting
into two groups representing the top (n = 24) and bottom quartiles (n = 28) for presence of
challenging behaviors. The participants with the highest levels of challenging behaviors had
higher levels of adaptive behavior, higher frequency of intermittent explosive/conduct disorder,
but lower frequency of epilepsy and cerebral palsy. All participants with the highest levels of
challenging behaviors lived in an institutional setting; whereas, those with the lowest level of
challenging behaviors lived in either an institutional setting or with their family. In participants
with severe/profound ID and multiple co-occurring disorders, a minimum level of adaptive be-
havior seems to be necessary for the expression of challenging behaviors.

What this paper adds?

Gain a better understanding of factors influencing the relationship between adaptive behavior and challenging behaviors in
individuals with ID and co-occurring conditions. Our study found that the relationship between adaptive behavior and challenging
behaviors changed as severity of ID increased. In fact, we found a positive relationship between adaptive behavior and challenging
behaviors in individuals with more severe to profound ID and several co-occurring disorders (epilepsy, blind/vision impairments,
cerebral palsy and intermittent explosive or conduct disorder). We also found that intermittent explosive and conduct disorder rather
than cerebral palsy or epilepsy were associated with the presence of challenging behaviors. Therefore, it seems that a minimum level
of adaptive behavior and motor skills are necessary to engage in certain challenging behaviors. Chronological age and sex did not
seem to affect the expression of challenging behaviors in individuals with co-occurring conditions. We also found that the participants
with the highest levels of challenging behaviors were more likely to live in institutional settings, whereas, half of the participants with

⁎
Corresponding Author at: Department of Philosophy, Social and Human Sciences and Education, University of Perugia, Piazza G. Ermini, 1,
06123, Perugia, Italy.
E-mail address: giulia.balboni@unipg.it (G. Balboni).

https://doi.org/10.1016/j.ridd.2020.103718
Received 19 March 2020; Received in revised form 1 June 2020; Accepted 12 June 2020
0891-4222/ © 2020 Elsevier Ltd. All rights reserved.
G. Balboni, et al. Research in Developmental Disabilities 104 (2020) 103718

the lowest level of challenging behaviors lived with their families. Therefore, in order to facilitate placement in the least restrictive
environments, it may be necessary to improve adaptive skills while also reducing challenging behaviors.

1. Introduction

Intellectual Disability (ID) is a neurodevelopmental disorder with an onset during the developmental period, and includes deficits
in intellectual functioning and adaptive behavior (American Psychiatric Association, 2013; Schalock et al., 2010). Adaptive behavior
is the collection of conceptual, social, and practical skills that have been learned and are performed daily by individuals (Tassé et al.,
2012). Conceptual skills involve both receptive and expressive language, reading, writing, math reasoning, and understanding of the
concepts of time and money. Social skills involve awareness of others’ thoughts and feelings, friendship abilities, ability to respect
social rules, and social judgment. Practical skills involve personal care, job responsibilities, money management and work task
organization (Schalock et al., 2010; Tassé et al., 2012). Deficits in adaptive behavior result in a failure to meet developmental and
sociocultural standards for personal independence and social responsibility expected for one’s chronological age. The DSM-5 pro-
posed determining the severity of ID (i.e., mild, moderate, severe, and profound) based on the severity of the individual’s adaptive
behavior deficits across conceptual, social, and practical skills (American Psychiatric Association, 2013).
Challenging behavior is defined as any behavior of such intensity, frequency or duration that it interferes with the individual’s
daily functioning (Emerson & Einfeld, 2011). More recently, the following operational definition has been proposed (Bowring,
Totsika, Hastings, Toogood, & Griffith, 2017; Nicholls, Hastings, & Grindle, 2020): any behavior may be defined as challenging if
either it’s rated as severe, or it’s rated as moderate and its frequency is at least weekly, or it’s rated as mild and occurs at least daily.
Much attention has been devoted to challenging behaviors of individuals with ID because they exhibit these behaviors at a higher
rate than the general population (e.g., Bowring et al., 2017; Grey, Pollard, McClean, MacAuley, & Hastings, 2010; Lunqvist, 2013).
The most common challenging behaviors exhibited by individuals with ID are aggression, self-injurious, and stereotyped behaviors
(Bowring et al., 2017; Cooper, Smiley, Allan et al., 2009, Cooper, Smiley, Jackson et al., 2009; Nicholls et al., 2020). However, any
behavior depending on its severity, intensity, or duration could meet the definition of challenging behaviors.
The presence of these challenging behaviors varies according to sociodemographic (i.e., chronological age and sex) and diagnostic
features. Regarding chronological age, it was found that the prevalence of challenging behaviors increases with age until early
adulthood, and persists over time (Davies & Oliver, 2013; Holden & Gitlesen, 2006). However, other studies in children, young adults
(Nicholls et al., 2020) and adults with ID (Bowring et al., 2017) have not reported a relationship between age and the presence of
challenging behaviors. Studies found that males with ID exhibited more challenging behaviors, at least in the case of aggression
(McClintock, Hall, & Oliver, 2003), than females (Emerson et al., 2001). However, other investigations have found the opposite result
(Jones et al., 2008) or have not find any relationship between sex and presence of challenging behaviors (Bowring et al., 2017;
Lunqvist, 2013; Nicholls et al., 2020). Studies have also shown that individuals with ID who live in institutional settings exhibited
more challenging behaviors than individuals with ID who live with their families (Borthwick-Duffy, 1994; Cooper, Smiley, Allan
et al., 2009, Cooper, Smiley, Jackson et al., 2009). The presence of challenging behaviors has often been cited as the reason for loss of
community placement (Allen, Lowe, Moore, & Brophy, 2007; Bruininks, Hill, & Morreau, 1988).
Regarding diagnostic features, previous studies have found that challenging behaviors are positively correlated to the severity of
ID: the more severe the level of disability, the more problem behaviors are pervasive and long-lasting (Bowring et al., 2017; Emerson
et al., 2001; Poppes, Van der Putten, & Vlaskamp, 2010), at least for self-injury and stereotypic behaviors (McClintock et al., 2003).
However, a recently published study found a negative relationship between the presence of challenging behaviors and profound ID
(Nicholls et al., 2020).
The increased presence of challenging behaviors may be associated with the presence of co-occurring disorders in individuals with
ID. For example, challenging behaviors were found to be associated with the presence of urinary incontinence, sleep disorders, and
pain associated with cerebral palsy (De Winter, Jansen, & Evenhuis, 2011) while self-injury was related to the presence of visual
impairment (Cooper, Smiley, Allan et al., 2009; De Winter et al., 2011). Aggression has been shown to be associated with the presence
of depression (Davies & Oliver, 2014; Reiss & Rojahn, 1993). Rojahn, Matson, Naglieri, and Mayville (2004) reported that adults with
severe-profound ID who presented with high rates of aggression and self-injurious behavior were more likely to present with co-
morbid impulse control disorder and behavioral problems. Conversely, no associations were found between increased challenging
behaviors and the presence of a hearing impairment (Bowring et al., 2017; De Winter et al., 2011; Jones et al., 2008), intestinal
incontinence (De Winter et al., 2011), epilepsy (Blickwedel, Ali, & Hassiotis, 2017; De Winter et al., 2011; Jones et al., 2008), and
motor impairment (De Winter et al., 2011; Jones et al., 2008).
In individuals with intellectual disability, challenging behaviors may serve different functions: receive attention, communicate
emotions, discomfort, needs (e.g., gain access to liked activities or items), escape demands (e.g., academic, daily living, or vocational
tasks), and/or self-stimulation or reduce physical discomfort or pain (Medeiros, Rojahn, Moore, & van Ingen, 2014; Schmidt et al.,
2016; Simó-Pinatella, Font-Roura, Alomar-Kurz, Giné, & Matson, 2014). These functions may not only reinforce the expression of
challenging behaviors but also may have the secondary effect of interfering with the learning and performance of adaptive skills
(Blickwedel, Vickerstaff, Walker, & Hassiotis, 2019; Chadwick, Kusel, & Cuddy, 2008; Nicholls et al., 2020). Previous studies have
reported an inverse relationship between adaptive behavior and challenging behaviors: the presence of greater adaptive skills has
been associated with fewer challenging behaviors (Blickwedel et al., 2019; Chadwick et al., 2008; Nicholls et al., 2020). Moreover,
the more serious the severity of ID, and consequently greater the limitations in the adaptive behavior, the higher the likelihood of the
presence of challenging behaviors (Borthwick-Duffy, 1994; McClintock et al., 2003). However, it is not clear which comes first,
whether deficits in adaptive skills lead to challenging behaviors or if challenging behaviors interfere with the learning and

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performance of adaptive behavior (Di Nuovo & Buono, 2007). In addition, it is not yet clear which personal characteristics might
affect this relationship between adaptive and challenging behaviors individuals with co-occurring disorders.
For this reason, we first investigated the relationship between adaptive behavior and challenging behaviors in individuals with ID
and co-occurring conditions (Study 1). Then, we examined the personal characteristics, such as chronological age, sex, severity of ID,
living arrangement and presence of co-occurring physical health (e.g., epilepsy and cerebral palsy) and mental health disorders (e.g.,
intermittent explosive or conduct disorder) and their potential impact on this relationship. To accomplish this aim, we compared the
participants in our study who were in the top and bottom quartiles of presence of challenging behaviors, as measured by the Nisonger
Child Behavior Rating Form (NCBRF; Aman, Tassé, Rojahn, & Hammer, 1996), on a number of personal characteristics as well on
adaptive behavior (Study 2).

2. Study 1

The first study aimed -to investigate the relationship between adaptive behavior and challenging behaviors in individuals with ID
and co-occurring physical health and mental health disorders.

2.1. Methods

2.1.1. Participants
Participants were 105 individuals (81 males, 77 %) aged from 3 to 48 years old (M = 26.26; SD = 12.74). Of them, 99 (94 %) had
ID (3 % of them had mild ID, 12 % moderate ID, 47 % severe ID, 29 % profound ID, and 8% unspecified ID). Four (4%) had a
borderline intellectual functioning and 2 (2 %) had a global developmental delay (these last two participants were the youngest aged
3 and 4 years old). The 105 participants also had the following co-occurring physical health disorders: epilepsy (45 %), blind or vision
impairment (43 %), cerebral palsy (36 %), and deaf/hearing impairment (9 %). They also had the following co-occurring mental
health disorders: intermittent explosive or conduct disorder (34 %), autism spectrum disorder (19 %), and attention-deficit/hyper-
activity disorder (5 %)..
All participants were recruited at the residential and out-patient facility Serafico, an Italian institutional and out-patient facility
specialized in the rehabilitation and education of individuals with severe sensory, physical, and mental disabilities. Participants were
included in the study based on the following inclusion criteria: having ID or a cognitive deficit and a co-occurring mental or physical
health condition. The majority of the participants (71 %) were living at the Serafico Institute. The remaining 29 % lived with their
biological or foster family and went to the Serafico Institute to participate in regular educational and rehabilitation services. Of them,
87 % were born in Italy and both parents were Italian, 6 % of participants were born in Italy but both parents were not Italian, 5 % of
participants were not born in Italy, and 3 % were born in Italy and only one parent was Italian. The majority of participants (70 %)
were not attending school and were receiving adult services; another 11 % of them were attending special schools and 18 % regular
schools.

2.1.2. Instruments
2.1.2.1. Vineland Adaptive Behavior Scales Second Edition Survey Form (Vineland-II). Vineland-II (Sparrow, Cicchetti, & Balla, 2005)
was used to assess the adaptive behavior of all participants. The Vineland-II consists of four scales (and 11 subscales): Communication
(Receptive, Expressive and Written subdomains), Daily living skills (Personal, Domestic and Community subdomains), Socialization
(Interpersonal relationships, Play and leisure time and Coping Skills subdomains), and Motor skills (Gross and Fine subdomains). The
Vineland-II yields a Composite Scale score for the measurement of the individual’s overall level adaptive behavior. The Vineland-II
was administered as a semi-structured interview to a caregiver of the individual being evaluated. Based on the caregiver’s answers,
the interviewer assigned a rating accordingly: “2” if the individual performs the skill always and independently, “1” if the individual
performs the skill sometimes or partially, and “0” if the individual never performs the skill. Standard Scores (M = 100; SD = 15) are
available for domains and Composite Scale and v-score (M = 15; SD = 3) for subdomains.
We used an Italian translation and adaptation of the Vineland-II which was developed following the procedures recommended by
Tassé and Craig (1999) and the International Test Commission (ITC) Guidelines for Translating and Adapting Test (International Test
Commission, 2017), and which was approved by Pearson publisher (Minneapolis, United States) (Balboni, Belacchi, Bonichini, &
Coscarelli, 2016). The original and Italian versions of the Vineland-II are both valid and reliable measures of adaptive behavior (for
use of the Italian version, see also: Balboni, Incognito, Belacchi, Bonichini, & Cubelli, 2017; Balboni, Tasso, Muratori, & Cubelli, 2016;
Tassé et al., 2019).

2.1.2.2. Nisonger Child Behavior Rating Form (NCBRF). The NCBRF (Aman et al., 1996) allows for the measurement of challenging
behaviors in individuals with ID. Two forms are available, one to be completed by parents and the other completed by teachers who
know well the assessed individual. Both NCBRF parent and teacher forms are composed of six scales that measure challenging
behavior: Conduct problem, Insecure/Anxious, Hyperactive, Self-injury/Stereotypic, Self-isolated/Ritualistic, Overly sensitive (only
the parent form) and Irritable (only the teacher form). There is also a total score that encompasses the overall level of an individual’s
challenging behaviors. Each item is rated according to the individual’s observed behavior during the previous month, according to
the following scale: 0 = if the behavior did not occur or was not a problem; 1 = if the behavior occurred occasionally or was a mild
problem; 2 = if the behavior occurred quite often or was a moderate problem; and 3 = if the behavior occurred a lot or was a severe
problem. Aman et al. (1996) developed the NCBRF for use with children and adolescents with ID. However, others have also used the

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NCBRF with adults (Weiss, Cappadocia, Tint, & Pepler, 2015) and its convergent validity has been established using the Behavior
Problems Inventory, a problem behavior rating instrument for children, adolescents and adults with ID (see Rojahn et al., 2012).
An Italian translation and adaptation of the NCBRF Parent form was developed (Balboni, Azzarelli, Makhluf, & Tassé, 2018;
Makhluf, Bacherini, Elisei, Tassé, & Balboni, 2020) in agreement with the ITC Guidelines for Translating and Adapting Test
(International Test Commission, 2017). With permission from the authors of the NCBRF, we decided to modify the rating scale. For
each item, the respondent was first asked if the individual had ever exhibited the behavior mentioned in the item stem by indicating
“Yes” or “No.” Then, if their response was “yes”, the respondent was prompted to assess the frequency and severity of the described
challenging behavior with the following rating scales: (a) frequency response scale: 0 = never; 1 = occasionally; 2 = quite often; and
3 = a lot; and (b) severity response scale: 0 = not a problem; 1= a mild problem (i.e., the behavior caused a mild impairment in
carrying out the individual’s daily activities); 2 = a moderate problem (i.e., the behavior caused a moderate impairment in carrying
out the individual’s daily activities, or interruption of others’ activities, or request for attention from others, without causing damage
to objects, oneself or others); and 3 = a severe problem (i.e., the behavior caused a severe impairment in carrying out the individual’s
daily activities, or need for restrictive or pharmacological interventions, or damage to objects, oneself or others).
The reliability and construct validity of the Italian NCBRF Parent form were investigated with the data collected in this study
(Makhluf et al., 2020). We found a very good reliability, investigated with the ordinal version of coefficients alpha (Zumbo,
Gadermann, & Zeisser, 2007), and good construct validity, investigated verifying the homogeneity of the scale (intercorrelation
between the scores on the NCBRF scales; Makhluf et al., 2020).

2.1.3. Procedure
Data collection was conducted between February and July 2018. Trained psychologists interviewed the participants’ caregivers on
the Vineland-II, these were the same caregivers who also completed the NCBRF. The two instruments were administered in a
counterbalanced order. Respondents were professional caregivers (direct support professionals [50 %], educators1 [50 %]). Thirty-six
percent of the respondents reported that they knew the participant for less than one year, 25 % knew the participant from one to three
years, and 39 % knew the participant for more than three years. All respondents and the parents/guardians for the participants
provided informed written consent. Participants’ and respondents’ anonymity was guaranteed. Participants and respondents did not
receive any form of incentive to participate in this study.

2.1.4. Data analysis

We computed the mean and SD of the normative scores across the Vineland-II scales and subscales and of the average rating on the
NCBRF scales (Conduct problem, Insecure/Anxious, Hyperactive, Self-injury/Stereotypic, Self-isolated/Ritualistic, Overly sensitive)
and total score for each frequency and severity rating. To investigate the relationship between adaptive behavior and challenging
behaviors, we computed the partial correlation coefficients between the raw scores on the Vineland-II scales and Composite Scale and
on the NCBRF scales and total score for frequency and severity rating with chronological age as a covariate variable. We used the raw
score instead of the normative scores because of the low variability of the participants’ normative scores. We introduced chron-
ological age as covariate variable of the correlation coefficient to account for the effect of chronological age on the raw score.

2.2. Results

Mean and SD of the normative scores on the Vineland-II scales, subscales, and Composite Scale are reported in Table 1. The
Vineland-II Composite Scale mean Standard Score was 23.44, which is approximately five SDs below the normative sample mean
score. The SD Standard Score equal to 7.32 is very low, indicating a low score variance with the majority of the participants’ Standard
Scores falling around the mean score. Low levels of adaptive behavior were also found for all the Vineland-II domains and sub-
domains. Because of the low variability of the participants’ normative scores, raw scores on the Vineland-II scales, subscales, and
Composite Scale were used in subsequent analyses.
Mean (SD) of the average rating on the NCBRF scales and total score for each frequency and severity rating are reported in Table 2
(the average rating ranged from 0 to 3). The mean of the average rating obtained by the participants across the total score and all
scales ranged from 0.11 to 0.78 and the SD ranged from 0.20 to 0.67. Therefore, it seems that the participants’ level of challenging
behavior was medium-low but with high variability.
Partial correlation coefficients between the raw scores on the Vineland-II scales and Composite Scale and the raw score on the
NCBRF scales and total score for frequency and severity rating, with chronological age as a covariate variable, were mostly positive
and ranged between -0.15 to 0.60 (median = 0.22).

3. Study 2

This second study aimed to compare sociodemographic and diagnostic characteristics, adaptive behavior and severity of chal-
lenging behaviors of the participants who were in the top and bottom quartiles of the number of expressed challenging behaviors.

1
An educator is a paid staff with formal university training to provide habilitation/rehabilitation instruction and supports to individuals with
disabilities

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Table 1
Mean (SD) of the Standard Scores on the Vineland-II Scales and Composite Scale and of the v-
scale Scores on the Vineland-II Subscales (n = 105).
Mean SD

Communication 21.69 5.48

Receptive 3.96 3.54
Expressive 2.50 2.90
Written 1.66 1.96
Daily living skills 22.58 7.64
Personal 1.77 1.68
Domestic 3.55 3.27
Community 1.61 1.60
Socialization 23.70 9.95
Interpersonal relationships 2.25 2.96
Play and leisure time 1.43 1.62
Coping skills 2.57 3.25
Motor skills 25.81 17.09
Gross 6.13 4.25
Fine 3.15 3.29
Composite Score 23.44 7.32

Table 2
Mean (SD) of the Average Rating on the NCBRF Scales and Total Score for Frequency and Severity Rating (n = 105).
Mean SD Minimum Maximum

Total Score
Frequency Rating 0.49 0.37 0.00 1.83
Severity Rating 0.25 0.28 0.00 1.68
Scale
Conduct problem
Frequency Rating 0.44 0.54 0.00 2.50
Severity Rating 0.31 0.49 0.00 2.63
Insecure/Anxious
Frequency Rating 0.23 0.31 0.00 1.73
Severity Rating 0.11 0.20 0.00 1.20
Hyperactive
Frequency Rating 0.78 0.67 0.00 2.63
Severity Rating 0.31 0.36 0.00 1.88
Self-injury/Stereotypic
Frequency Rating 0.40 0.56 0.00 2.43
Severity Rating 0.28 0.47 0.00 2.57
Self-isolated/Ritualistic
Frequency Rating 0.64 0.53 0.00 2.14
Severity Rating 0.20 0.24 0.00 1.00
Overly sensitive
Frequency Rating 0.62 0.65 0.00 3.00
Severity Rating 0.30 0.44 0.00 2.50

Note: The frequency and severity rating ranged from 0 to 3.

3.1. Methods

3.1.1. Participants
Two groups of individuals were selected from the 105 participants, which made up of the 25 % of individuals who presented the
lowest number (Group 1, n = 24) and the 25 % of those who presented the highest number (Group 2, n = 28) of endorsed items (i.e.,
challenging behaviors) on the NCBRF. Table 3 presents their sociodemographic and diagnostic characteristics.

3.1.2. Data analyses

Student’s t-test was used to investigate the differences between Groups 1 and 2 on chronological age, raw scores on the Vineland-II
scales, subscales, and Composite Scale, and average rating on the NCBRF scales and total score for each frequency and severity rating.
Chi2 test was used to investigate if there were any differences between Groups 1 and 2 on sex, aggregate severity of ID, living
arrangement, and co-occurring physical health and mental health disorders (Chi2 was not computed for cases with expected fre-
quency lower than five). Given the number of comparisons with the same participants, we computed p values by means of the False
Discovery Rate procedure to minimize Type I error (Benjamini & Yekutieli, 2001). In cases of statistically significant differences, we
computed Cohen's d and w for t-test and Chi2 test results, respectively; they were interpreted as follows: negligible (d < 0.20,
w < 0.10), small (0.20 ≤ d < 0.50, 0.10 ≤ w < 0.30), medium (0.50 ≤ d < 0.80, 0.30 ≤ w < 0.50), or large (d ≥ 0.80, w ≥ 0.50)

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Table 3
Sociodemographic and Diagnostic Characteristics of the 25 % of Individuals Who Expressed the Lowest Number (Group 1) and
the 25 % of Those Who Expressed the Highest Number (Group 2) of Challenging Behaviors.
Group 1 Group 2
(n = 24) (n = 28)

Age
M (SD) 23.76 (12.77) 28.90 (12.12)
Range 3.82 – 48.22 5.85 – 47.10
Sex (%)
Male – Female 19 (79) – 5 (21) 20 (71) – 8 (29)
Aggregate Severity of ID (%)
Mild/moderate - Severe/profound 4 (20) – 16 (80) 8 (29) – 20 (71)
Living arrangement (%)
Institutional setting – Original/foster family 11 (46) – 13 (54) 28 (100) – 0 (0)
Co-occurring health disorders (%)
Epilepsy 15 (62) 6 (21)
Blind/vision impairments 10 (42) 12 (43)
Deaf/hearing impairments 4 (17) 2 (7)
Cerebral palsy 20 (83) 3 (11)
Co-occurring mental health disorders (%)
Intermittent explosive or conduct disorder 2 (8) 20 (71)
Autism spectrum disorders 1 (4) 8 (29)
Attention-deficit/hyperactivity disorder 0 (0) 2 (7)

(Cohen, 1988).

3.2. Results

3.2.1. Comparisons between the sociodemographic and diagnostic characteristics of the individuals who expressed the lowest and the highest
number of challenging behaviors
The two groups did not differ statistically on chronological age, sex, aggregate severity of ID and the presence of blind/vision
impairments. Conversely, the individuals who presented the highest number of challenging behaviors, were more likely to be living in
an institutional setting (Chi2(1) = 20.22, p < 0.001, w = .62) rather than with their family, had more frequently intermittent explosive
or conduct disorder (Chi2(1) = 21.08, p < 0.001, w = .64), but were less likely to have epilepsy (Chi2(1) = 9.05, p < 0.05, w = .41) and
cerebral palsy (Chi2(1) = 27.63, p < 0.001, w = .73). Chi2 was not computed to compare the two groups on the frequency of deaf/
hearing impairments, ADHD, and autism spectrum disorder because the expected frequencies were < 5.

3.2.2. Comparisons between the level of adaptive and challenging behaviors of the individuals who expressed the lowest and the highest
number of challenging behaviors
As shown in Table 4, individuals who presented higher rates of challenging behaviors presented statistically significant higher
levels of adaptive behavior on the Vineland-II Composite Scale and on the scales (subscales) of Communication (Receptive and
Expressive), Daily living skills (Personal and Domestic), Motor skills (Gross and Fine), and on the Interpersonal relationship subscale.
The effect size was always large except for the Expressive and Interpersonal relationships which had a medium effect size. This group
also presented statistically significant higher scores on all the NCBRF scales and total score for frequency and severity rating (with a
large effect size).

3.3. Discussion

The main purpose of the present study was to investigate the personal characteristics that might affect the relationship between
adaptive and challenging behaviors in individuals with ID and co-occurring physical and mental health disorders. First, we in-
vestigated the relationship between adaptive behavior and challenging behaviors in individuals with mostly severe and profound ID
and with several co-occurring conditions (e.g., epilepsy, blind/vision impairment, cerebral palsy, and intermittent explosive or
conduct disorder). Surprisingly, we found a positive relationship between adaptive and challenging behaviors. In other words, higher
levels of adaptive behavior were more likely to be associated with the presence of challenging behaviors: a basal level of adaptive
skills appear to be necessary for the person to be able to engage in their environment. At times this expresses itself by emitting
challenging behaviors, sometimes as a vehicle for communication of their wants and needs. These results are inconsistent with those
of previously published studies (Blickwedel et al., 2019; Chadwick et al., 2008; Nicholls et al., 2020), which have generally reported
an inverse relationship between levels of adaptive behavior and challenging behaviors in individuals with ID. This inconsistency
could be due to the characteristics of our participants, being individuals with substantially severe and profound deficits in intellectual
and adaptive functioning and with co-occurring conditions. Perhaps a minimal ability is needed at this lower range of functioning for
the individual to be cognizant of the cause-effect relationship of using challenging behavior to serve as a behavioral function.
To better understand the factors that might be attributed to result, we compared the personal characteristics and adaptive

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Table 4
Comparisons Between the 25 % of Individuals Who Expressed the Lowest Number (Group 1) and the 25 % of Those Who Expressed the Highest
Number (Group 2) of Challenging Behaviors on the Raw Scores on the Vineland-II Scales, Subscales and Composite Scale and on the Average Rating
on the NCBRF Scales and Total Score for Frequency and Severity Rating.
Group 1 Group 2
(n = 24) (n = 28)
M (SD) M (SD) t values Cohen’s d

Vineland-II
Communication 25.29 (41.97) 63.43 (53.32) 2.88** 0.80
Receptive 8.63 (9.18) 19.46 (12.01) 3.68*** 1.02
Expressive 15.33 (29.04) 38.39 (34.32) 2.62* 0.73
Written 1.33 (6.53) 5.57 (11.31) 1.68
Daily living skills 11.75 (25.97) 55.18 (38.49) 4.83*** 1.32
Personal 7.21 (12.22) 38.50 (18.85) 7.20*** 1.98
Domestic 0.46 (2.04) 6.93 (9.37) 3.56** 0.93
Community 4.08 (13.05) 9.75 (13.02) 1.56
Socialization 27.33 (43.20) 47.39 (38.41) 1.77
Interpersonal relationships 14.33 (17.99) 25.79 (18.04) 2.29* 0.65
Play and leisure time 6.42 (11.46) 10.32 (10.95) 1.26
Coping skills 6.58 (14.54) 11.29 (13.41) 1.21
Motor skills 13.42 (19.28) 81.93 (33.99) 9.10*** 2.48
Gross 8.38 (11.68) 53.93 (17.93) 10.99*** 3.02
Fine 5.04 (12.34) 28.00 (18.33) 5.36*** 1.48
Composite Scale 77.79 (119.91) 247.93 (152.52) 4.50*** 1.25
NCBRF
Total Score
Frequency Rating 0.09 (0.06) 0.90 (0.37) 11.48*** 3.02
Severity Rating 0.03 (0.04) 0.54 (0.37) 7.23*** 1.90
Scale
Conduct problem
Frequency Rating 0.02 (0.03) 1.00 (0.64) 8.15*** 2.14
Severity Rating 0.00 (0.01) 0.79 (0.70) 5.99*** 1.57
Insecure/Anxious
Frequency Rating 0.03 (0.04) 0.50 (0.43) 5.74*** 1.51
Severity Rating 0.01 (0.03) 0.27 (0.30) 4.51*** 1.18
Hyperactive
Frequency Rating 0.22 (0.29) 1.17 (0.74) 6.29*** 1.68
Severity Rating 0.08 (0.18) 0.51 (0.49) 4.30*** 1.15
Self-injury/Stereotypic
Frequency Rating 0.05 (0.12) 0.77 (0.75) 4.94*** 1.30
Severity Rating 0.01 (0.04) 0.61 (0.70) 4.55*** 1.19
Self-isolated/Ritualistic
Frequency Rating 0.17 (0.22) 0.86 (0.45) 7.15*** 1.93
Severity Rating 0.06 (0.11) 0.30 (0.28) 4.18*** 1.12
Overly sensitive
Frequency Rating 0.17 (0.26) 1.06 (0.76) 5.87*** 1.56
Severity Rating 0.04 (0.12) 0.70 (0.61) 5.56*** 1.47

Note: The frequency and severity rating ranged from 0 to 3.

behavior of participants in our study who were in the top and bottom quartiles of presence of challenging behaviors. The 25 % of the
participants with the highest level of challenging behaviors had higher levels of adaptive behavior in the Communication, Daily living
skills, and Motor skills Vineland-II scales than the 25 % of participants with the lowest level of challenging behaviors.
Looking more closely at the personal characteristics of these two groups, we found that there did not differ on chronological age,
sex, severity of ID, and presence of blind/vision impairment. On the contrary, those with the highest level of challenging and adaptive
behaviors presented with higher rates of intermittent explosive or conduct disorder, but lower rated of epilepsy and cerebral palsy.
These results seem inconsistent with previously published studies that have reported that challenging behaviors are greater in in-
dividuals with more severe levels of impairment (Bowring et al., 2017; Emerson et al., 2001; Poppes et al., 2010). Conversely, our
results are consistent with the recently published studies that found no relationship between age and sex, with the presence of
challenging behaviors (Bowring et al., 2017; Nicholls et al., 2020). There is also agreement between the main features of the in-
termittent explosive or conduct disorder diagnostic criteria (see American Psychiatric Association, 2013), such as problems of self-
control of emotions and behaviors which are generally associated with challenging behaviors. Likewise, previous studies (De Winter
et al., 2011; Jones et al., 2008) have frequently reported that epilepsy and cerebral palsy were not associated with higher rates of
challenging behaviors.
Overall, it seems that for individuals with mostly severe and profound ID and with co-occurring physical and mental health
conditions, the presence of challenging behaviors could be related to the type of co-occurring conditions (intermittent explosive or
conduct disorder rather than cerebral palsy), and not to the severity of ID, chronological age or sex. In particular, individuals with ID
and severe cerebral palsy may not have the necessary physical ability to engage in certain challenging behaviors. It seems that

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minimum levels of adaptive behavior and motor skills are necessary to engage in certain challenging behaviors (e.g., aggression
towards others or self-injurious behaviors). In other words, it seems that the positive correlations that we found between adaptive and
challenging behaviors may be due to the level of severity of ID and the type of associated behaviors. In the case of individuals with
mostly severe and profound ID, their substantial deficits in adaptive functioning may indicate that there is a required base level of
adaptive behavior that may be necessary, but not sufficient, for the expression of certain challenging behaviors. This interpretation
may corroborate similar findings in a recent study (Nicholls et al., 2020) that found a negative correlation between the presence of
challenging behaviors and profound ID.
Especially in individuals with very low levels of adaptive skills, challenging behaviors may be a way (sometimes the only way) to
communicate with their environment, express their emotions, discomfort, or needs, ask for attention or to escape from unpleasant
situations (Medeiros et al., 2014; Schmidt et al., 2016; Simó-Pinatella et al., 2014). Therefore, some questions come up: how can the
individuals who do not have the requested minimum level of adaptive behavior to engage in challenging behaviors express their
personal needs? Which methods may be used to at least have an idea of their needs, discomfort and emotions? How personal needs
can be investigated to plan a system of supports?
Interestingly, we have also found that the individuals with the highest level of challenging behaviors lived in an institutional
setting, whereas half of the participants in our sample with the lowest level of challenging behaviors lived in an institutional setting,
while the other half lived with their family. It seems that, individuals with mostly severe and profound ID and co-occurring physical
and mental health conditions, living in an institutional setting was not correlated with their level of adaptive behavior. On the
contrary, it seems to be related with the presence of co-occurring conditions like an intermittent explosive or conduct disorder which
are connected with challenging behaviors. This is consistent with previous findings that have reported that the presence of chal-
lenging behaviors has often been cited as the justification for maintenance in a restrictive living setting or the loss of community
placement (Allen et al., 2007; Bruininks et al., 1988). However, based on our study it can be said that, in the case of severe and
multiple conditions, in order to facilitate the placement in the least restrictive environments, it may be necessary to improve adaptive
skills while taking action to reduce the challenging behaviors. At the same time, one must be cautious because increasing adaptive
skills can be associated with an increase in challenging behaviors.
Our results need to be interpreted within the context of a number of study limitations. First, the instrument used, the NCBRF, is a
measure originally designed for use with children. Other investigators have found it to have good psychometric properties with adults
(Weiss et al., 2015), thus supporting its with adults. However, additional studies are needed to establish the validity of the NCBRF
with an adult population.
The participants of the present investigation mostly presented with severe and profound ID. Further investigations are needed that
include participants who present with mild and moderate ID and co-occurring conditions to investigate the relationship between
adaptive behavior and challenging behaviors, and how this relationship is affected by the co-occurring conditions in individuals with
less severe forms of ID.
Further studies must also be conducted to properly account for a wider range in chronological age and more even distribution of
males and females in the participant sample. Regarding chronological age range, we took into account this issue in Study 1 by
introducing chronological age as a covariate variable in the correlation coefficients, and in Study 2 by matching on chronological age
the two groups of individuals who expressed the lowest and the highest number of challenging behaviors. Similarly, the two groups
were matched also on sex. It is well known that ID is slightly more prevalent in males than in females (American Psychiatric
Association, 2013). However, further investigations should be conducted with participants with a more restricted chronological age
range and with more females.
Moreover, the participants were recruited from one regional institution offering residential and out-patient services. This is a
relevant limitation for the generalization of our findings. However, this study is not an epidemiological study. Having been recruited
from the same setting guarantees that they have received the same social and physical context as well as the same type of inter-
ventions. These are factors that may affect the expression of adaptive behavior and challenging behaviors; therefore, having these be
constant, reducing some confounding variables that may affect the relationships between adaptive behavior and challenging beha-
viors.

3.3.1. Conclusions
However, despite these limitations, based on our study it can be said that in case of severe ID and multiple co-occurring con-
ditions, a minimum level of adaptive behavior is a necessary, but not sufficient, condition for the expression of challenging behaviors.
Moreover, in order to facilitate the placement in the least restrictive environment, it may be necessary to improve adaptive skills and
take action on reducing challenging behaviors, while being vigilant regarding the possibility that increasing adaptive skills can be
associated with the expression of more challenging behaviors.

Funding

This research did not receive any grant funding.

Ethical standards

This study was conducted in accordance with the ethical standards laid down in the 2013 Fortaleza version of the Declaration of
Helsinki. Informed consent was obtained from the legal guardians of each participant.

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CRediT authorship contribution statement

Giulia Balboni: Conceptualization, Data curation, Formal analysis, Methodology, Software, Supervision, Writing - original draft,
Writing - review & editing. Gessica Rebecchini: Writing - original draft. Sandro Elisei: Investigation, Resources. Marc J. Tassé:
Conceptualization, Methodology, Supervision, Writing - review & editing.

Declaration of Competing Interest

The authors declare that they have no conflict of interest.

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