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The Missing Link: Delayed Emotional Development Predicts Challenging

Behavior in Adults with Intellectual Disability

Article  in  Journal of Autism and Developmental Disorders · September 2013

DOI: 10.1007/s10803-013-1933-5 · Source: PubMed

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J Autism Dev Disord (2014) 44:786–800
DOI 10.1007/s10803-013-1933-5
ORIGINAL PAPER
The Missing Link: Delayed Emotional Development Predicts
Challenging Behavior in Adults with Intellectual Disability
Tanja Sappok • Jan Budczies • Isabel Dziobek •
Sven Bölte • Anton Dosen • Albert Diefenbacher
Published online: 4 September 2013
Ó Springer Science+Business Media New York 2013
Abstract Individuals with intellectual disability (ID)
show high rates of challenging behavior (CB). The aim of
this retrospective study was to assess the factors underlying
CB in an adult, clinical ID sample (n = 203). Low levels
of emotional development (ED), as measured by the
Scheme of Appraisal of ED, predicted overall CB, specif-
ically irritability and self-injury, high unemployment and
low occupation rates, while severity of ID controlled for
ED did not. Autism was the only mental disorder associ-
ated with overall CB, stereotypy, lethargy, and predicted
antipsychotic drug usage. Given the persistence and clini-
cal significance of CB, evaluation of autism and ED may
suggest priority areas for diagnostics and therapy, to pro-
vide the prerequisites for participation in society and living
up one’s potentials.
T. Sappok (&)  A. Diefenbacher
Department of Psychiatry, Psychotherapy and Psychosomatics,
Königin-Elisabeth-Herzberge Hospital, University Affiliated
Hospital of the Charité, Herzbergstr.79, 10365 Berlin, Germany
e-mail: tanja.sappok@t-online.de
J. Budczies
Department of Pathology, Charité University Hospital,
Charitéplatz 1, 10117 Berlin, Germany
I. Dziobek
Cluster of Excellence Languages of Emotion, Freie Universität
Berlin, Habelschwerdter Allee 45, 14195 Berlin, Germany
S. Bölte
Department of Women’s and Children’s Health, Center of
Neurodevelopmental Disorders at Karolinska Institutet (KIND),
17176 Stockholm, Sweden
A. Dosen
Department of Psychiatry, University Hospital, Radboud
University, Comeniuslaan 4, 6525 HP Nijmegen, Netherlands
123
Keywords Intellectual disability  Autism spectrum
disorders  Adults  Emotional development 
Challenging behavior
Introduction
Individuals with intellectual disability (ID) show high point
prevalence rates of mental health problems and challeng-
ing behaviors, approximately 40 and 20 %, respectively
(Cooper et al. 2007). In ID, the presence of autism spec-
trum disorders (ASDs) and the severity of ID are the most
important predictors for referrals to psychiatrists and pre-
scription of psychotropic drugs, as well as the predominant
causes of challenging behavior (Bhaumik et al. 2008; Es-
bensen et al. 2009; Tsakanikos et al. 2007; Witwer and
Lecavalier 2005). A multitude of studies have shown that
adults with ID and ASD demonstrate high levels of chal-
lenging behavior (Hill and Furniss 2006; Holden and Gi-
tlesen 2006; Hove and Havik 2010; Kraijer 2000;
McCarthy et al. 2010; McClintock et al. 2003; Underwood
et al. 2010). In adults, according to McCarthy et al. (2010),
challenging behavior is approximately four times more
likely in ASD/ID combined than in those with ID only.
Challenging behaviors are already increased in childhood,
(Murphy et al. 2009) and tend to persist over the life span,
especially in individuals with ASD and low verbal abilities
(Matson and Rivet 2008; Murphy et al. 2005). Challenging
behavior is associated with other psychiatric morbidity and
is an important barrier for access to education, participation
in society, and living up one’s personal and professional
potentials (De Bildt et al. 2005; Emerson et al. 2000; Felce
et al. 2009; Holden and Gitlesen 2006). A reduction of
challenging behavior and an increase of adaptive behavior
seem to be important in improving mental health and the
J Autism Dev Disord (2014) 44:786–800
overall quality of life in affected individuals (Ciarrochi and
Scott 2006; Rey et al. 2012). Finally, ASD-related chal-
lenging behaviors have been consistently associated with
the psychological well-being and emotional problems of
caregivers (Lounds et al. 2007; Totsika et al. 2011). The
mechanisms that lead to high levels of challenging
behavior among ASD/ID individuals yet are poorly
understood (McCarthy et al. 2010).
The severity of challenging behaviors and psychopa-
thology rises with the increasing severity of ID and ASD-
defining symptomatology (Matson and Rivet 2008; Matson
et al. 2009a, b; McCarthy et al. 2010). Moreover, as
challenging behavior changes and tends to decrease with
age, developmental factors may play a role (De Bildt et al.
2005; Felce et al. 2009; Maskey et al. 2013; Murphy et al.
2009; Totsika et al. 2011). Alteration in emotion-process-
ing such as difficulties in perception, recognition, under-
standing, expression, and regulation of emotions could be
found in ASD (Begeer et al. 2008; Hobson 1986; Kasari
et al. 2012). Hence, the quality and severity of challenging
behavior may depend not only on intellectual but also on
emotional skills changing over a lifetime. The effect of the
overall emotional development (ED) on challenging
behavior has not yet been examined in individuals with ID.
Emotional Development
In this study, we consider the ‘concept of ED’ in terms of a
developmental approach (Dosen 2005; Greenspan 1979;
Izard et al. 2006; Sroufe 2009), i.e., acquisition of emo-
tional competencies following a progressive sequence of
qualitative changes incorporating predominantly emotional
but also social, sensorimotor, and cognitive functions on
the background of normal development in infants. The
various components of ED reciprocally interact and stim-
ulate each other for a further maturation of the individual
and an optimal adaptation to the environment. While
newborns already show, perceive, and respond to a range
of simple emotions, within the first year of life, the emo-
tional response is modulated by the affect of the interaction
partner (Bertin and Striano 2006; Stern 2007). Around the
second year of life, affective sharing arises in the context of
‘joint attention’ (Kasari et al. 1990; Trevarthen 1980).
Gradually, emotional responses and emotion regulation
become more complex and around the third year of life,
children are able to manipulate the emotional states of
others, e.g., by teasing or cooperating behaviors (Jackson
and Tisak 2001). Preschoolers can differentiate, regulate,
and integrate their affective states and have a basic insight
into the causes and consequences of emotions. Further
progress in empathy, pro-social behaviors, and moral
thinking is observed in school-aged children (Rieffe et al.
2005). These age-appropriate changes of ED are the basis
787
for the onset of the concept of ‘‘self’’ and the formation of
personality structures (Dosen 1997). This emotional mat-
uration process is assumed to be a product of multiple
internal and external factors. First, cerebral circuits
responsible for survival (e.g., feeding, reproduction, or
social contact) are conducive for basic emotions (Damasio
2010). Second, ED is intertwined and closely accompanied
by cognitive developmental changes (Pessoa 2010; Piaget
1953). ‘Object constancy’, for example, is defined as an
internal representation of the outside environment (Piaget
1953) and results in the formation of ‘emotional object
constancy’ (Mahler et al. 1975). Emotional object con-
stancy is essential for the sense of self-boundaries and for
internalization of the representation of ‘love objects’,
leading to secure attachment and consequently individu-
alization (Bowlby 1969). Third, ED is anchored in social
interaction. Mirroring the emotions of a child in a secure
setting further supports emotion regulation, expression, and
modulation (Kernberg 2012). Finally, environmental fac-
tors and sensory abilities necessary for an appropriate
perception of the environment may influence emotional
reactivity and emotion regulation strategies (Aldao and
Nolen-Hoeksema 2012). Thus, a multitude of cognitive,
social, sensorimotor, and environmental factors closely
interact with and stimulate each other, resulting in the
concept of overall ED. Each level of ED is associated with
specific basic emotional needs and motivations, certain
coping strategies, and adaptive behavior outcomes. Gen-
erally, individuals with ID pass through the same periods of
ED as typically developing children do, although with an
increased risk of delay and incompleteness (Greenspan
1997; Hodapp and Zigler 1995).
Currently, in addition to the treatment of physical ill-
nesses and changes in psychosocial environmental factors,
applied behavior analysis is the favored assessment and
therapy for challenging behavior among ID individuals
(Didden et al. 1999; Matson et al. 2011). Combining these
strategies with the developmental approach might lead to
an increase in emotional capacities and thus further
improve functional life skills, quality of life, and well-
being (Rey et al. 2012).
On the background of the developmental understanding
of ED, Dosen (1997) designed the Scheme of Appraisal of
Emotional Development (SAED) to assess emotional
maturity according to the normative trajectory of typically
developing children. The SAED is a semi-structured inter-
view of a significant other classifying the present level of
development in 10 domains (cf. ‘‘Methods’’ section) and an
overall level of ED. Table 1 summarizes these different ED
levels, the age-equivalents of typically developing children,
and the major achievements within the assigned periods.
In summary, individuals with ID show high prevalence
rates of challenging behaviors leading to a considerable
123
788 J Autism Dev Disord (2014) 44:786–800

Table 1 Levels of ED, age equivalents and developmental achievements according to the SAED
Level of ED Age Developmental achievements

1: Adaptation 0–6 months Homeostasis; integration of internal; e.g., sensory stimuli; bowel movements; and external stimuli; e.g.,
time; place; caregivers
2: Socialization 6–18 months Attachment; emotional security; confidence
3: Individuation 18–36 months Differentiation of self from others; autonomy; management of separation from a bonding person; object
permanence
4: Identification 3–7 years Ego-formation; ego-centered; identification with significant others; little abstract thinking; evolving social
skills; learn by experience
5: Reality 7–12 years Reflective thinking; emerging moral thinking and self-respect; ego-differentiation; reasoning
awareness

health burden, reduction of quality of life as well as par-
ticipation in social life. The aim of the present study was
(A) to assess the impact of various mental disorders
including ASD, the level of ED, the degree of ID, age, and
gender on the severity of challenging behavior and
aggression in adults with ID and (B) on outcome variables
such as living and working situation and on medication
usage.
completed by a psychologist (H.K.), the MOAS and the
remaining SAED assessments were evaluated by the
attending psychiatrist; the ABC was assessed by a care-
giver, all not involved in the study. The study was con-
ducted according to the recommendations of the
declaration of Helsinki.
Participants

In total, 203 participants (64 females, 139 males) were

Methods
Setting and Design
The study was conducted at a psychiatric department in a
general hospital with a specialized in- and outpatient unit
for adults with ID. This specialized unit has the responsi-
bility to assess and treat all adults with ID and comorbid
mental or severe behavioral problems in Berlin (popula-
tion 3.5 million), Germany. Aggressive and challenging
behaviors were assessed with the Modified Overt Aggres-
sion Scale (MOAS) and the Aberrant Behavior Checklist
(ABC) in 203 adults with ID referred to the center between
1/2008 and 6/2012. This cohort was comprehensively
examined with regard to the presence of pervasive or
emotional developmental disorders (cf. diagnostic proce-
dures and test materials), mental health, physical comor-
bidities, medication, employment, and living situation.
Assessments of developmental disorders were conducted
after remission of the acute exacerbation of the mental
illness in the in- or outpatient clinic. The impact of the
mental disorders, level of ED, severity of ID, and baseline
variables on problem behaviors and outcome variables
were calculated by correlation and regression analysis.
All assessments were part of the clinical routine and
data analysis performed retrospectively from the hospital
database. Evaluation of existing diagnostic data is based on
the legal requirements in Berlin, Landeskrankenhausgesetz
§ 25.1, version 18.09.2011. All data was anonymized.
The ASD measures and most SAED evaluations were
included in the study. None of the participants lived in a
long-term psychiatric institution; all lived with their fam-
ilies or in residential homes with a maximum group size of
8 inhabitants. Inclusion criteria in this naturalistic study
design were age [18 years, intellectual disability of any
degree, hospital referral from 1/2008 to 6/2012, and stan-
dardized behavioral assessment with the MOAS and the
ABC for clinical purposes. The mean age was 35.8
(SD = 12.6) years; the degree of ID was mild (n = 39),
moderate (n = 89), and severe-profound (n = 75). Eighty-
six individuals were diagnosed with additional ASD, 117
were not (non-ASD). Table 2 shows the baseline charac-
teristics of the total study sample, including ASD and non-
ASD individuals.
Diagnostic Procedures
Assessment of Neurological and Mental Disorders
All individuals were thoroughly evaluated by a psychiatrist
trained in medical assessment and treatment of individuals
with ID. Evaluation comprised the current and past medical
history and a comprehensive psychiatric and physical
examination. In case of diagnostic uncertainty, laboratory
examinations, brain imaging (cCT, cMRT), X-rays, elec-
troencephalography, neurophysiological measures, and
clinical assessment by specialists, e.g., a neurologist,
ophthalmologist, ear-nose-throat physician, or surgeons
were applied. Neurological disorders leading to functional
impairments of daily living skills were grouped according

123
J Autism Dev Disord (2014) 44:786–800 789

Table 2 Baseline characteristics of the study population

Characteristic Total sample ID & ASD ID, no ASD p

General Information, n (%) 203 (100 %) 86 (42.4 %) 117 (57.6 %)

Gender (male), n (%) 139 (68.5 %) 63 (73.3 %) 76 (65.0 %) .209
Age in years, M (SD) 35.79 (12.57) 34.97 (11.48) 36.40 (13.34) .423a
Severity of ID n (%) 203 (100 %) 86 (42.4 %) 117 (57.6 %) .001*,b
Mild 39 (19.2 %) 10 (11.6 %) 29 (24.8 %) .019
Moderate 89 (43.8 %) 33 (38.4 %) 56 (47.9 %) .178
Severe-profound 75 (36.9 %) 43 (50.0 %) 32 (27.4 %) .001
Level of ED n (%) 203 (100 %) 86 (42.4 %) 117 (57.6 %) \.0005*,b
SAED 1 (0–6 months) 13 (6.4 %) 10 (11.6 %) 3 (2.6 %) .009
SAED 2 (6–18 months) 30 (14.8 %) 19 (22.1 %) 11 (9.4 %) .012
SAED 3 (18–36 months) 68 (33.5 %) 40 (46.5 %) 28 (23.9 %) .001
SAED 4 (3–7 years) 50 (24.6 %) 13 (15.1 %) 37 (31.6 %) .007
SAED 5 (7–12 years) 42 (20.7 %) 4 (4.7 %) 38 (32.5 %) \.0005
SAED level, M (SD) 3.40 (0.85) 2.88 (0.96) 3.79 (0.77) \.0005
Neurological disorders N (%) 203 (100 %) 86 (100 %) 117 (100 %)
Hearing deficits 11 (5.4 %) 5 (5.8 %) 6 (5.1 %) .831
Visual deficits 26 (12.8 %) 10 (11.6 %) 16 (13.7 %) .666
Movement disorder 24 (11.8 %) 5 (5.8 %) 19 (16.2 %) .023*
Seizure disorder 50 (24.6 %) 21 (24.4 %) 29 (24.8 %) .952
Mental disorders, N (%) 203 (100 %) 86 (100 %) 117 (100 %)
Dependency disorders (F1x.x) 12 (5.9 %) 7 (8.1 %) 5 (4.3 %) .248
Schizophrenia (F2x.x) 52 (25.6 %) 31 (36.0 %) 21 (17.9 %) .004*
Mood disorders (F3x.x) 64 (31.5 %) 23 (26.7 %) 41 (35.0 %) .209
Neurotic, stress-related and somatoform disorders (F4x.x) 35 (17.2 %) 17 (19.8 %) 18 (15.4 %) .414
Personality disorders (F6x.x) 12 (5.9 %) 0 (0 %) 12 (10.3 %) .002*
Medication, n (%) 202 (100 %) 86 (100 %) 116 (100 %)
Antipsychotics-high potency 116 (57.4 %) 60 (69.8 %) 56 (48.3 %) .002*
Antipsychotics-low potency 89 (44.1 %) 47 (54.7 %) 42 (36.2) .009*
Antidepressants 45 (22.3 %) 16 (18.6 %) 29 (25.0 %) .280
Anticonvulsive drugs 77 (38.1 %) 32 (37.2 %) 45 (38.8 %) .819
Benzodiazepines 32 (15.9 %) 18 (20.9 %) 14 (12.2 %) .093
Living situation, n (%) 200 (100 %) 86 (100 %) 114 (100 %) .423c
Alone 3 (1.5 %) 0 3 (2.6 %) .261c
Living with family 23 (11.5 %) 10 (11.6 %) 13 (11.4 %) .961
Residential home 174 (87.0 %) 76 (88.4 %) 98 (86.0 %) .616
Employment, n (%) 197 (100 %) 85 (100 %) 112 (100 %) .001c,*
Unemployed 40 (20.3 %) 24 (28.2 %) 16 (14.3 %) .016*
In School 6 (3.0 %) 5 (5.9 %) 1 (0.9 %) .087c
In Rehab program 67 (34.0 %) 32 (37.6 %) 35 (31.2 %) .348
Sheltered work 80 (40.6 %) 22 (25.9 %) 58 (51.8 %) \.0005*
Retirement 4 (2.0 %) 2 (2.4 %) 2 (1.8 %) 1.000
ABC, N (%) 203 (100 %) 86 (100 %) 117 (100 %)
Total score, M (SD) 46.83 (26.48) 56.55 (26.51) 39.68 (24.18) .001*,d
Irritability, M (SD) 14.65 (9.44) 16.65 (9.45) 13.17 (9.19) .008*,d
Lethargy, M (SD) 11.39 (9.07) 14.45 (9.48) 9.15 (8.08) .001*,d
Stereotypy, M (SD) 4.69 (4.78) 6.60 (4.71) 3.13 (4.29) .001*,d
Hyperactivity, M (SD) 13.16 (9.72) 15.67 (10.96) 11.32 (8.26) .007*,d
Inappropriate speech, M (SD) 3.04 (3.24) 3.20 (3.22) 2.92 (3.26) .516d

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790 J Autism Dev Disord (2014) 44:786–800

Table 2 continued
Characteristic Total sample ID & ASD ID, no ASD p

MOAS, N (%) 203 (100 %) 86 (100 %) 117 (100 %)

Total score, M (SD) 4.93 (3.51) 4.62 (3.67) 5.35 (3.25) .110d
Aggression: verbal, M (SD) 1.27 (1.23) 1.10 (1.22) 1.39 (1.23) .047d
Aggression: objects, M (SD) 1.30 (1.22) 1.40 (1.27) 1.22 (1.17) .365d
Aggression: self, M (SD) 1.16 (1.17) 1.45 (1.09) 0.94 (1.18) .001*,d
Aggression: others, M (SD) 1.29 (1.28) 1.46 (1.26) 1.16 (1.28) .075d
Differences between ASD and non-ASD individuals were calculated by 2-sided Pearson’s v2 tests except a indicates t Test, b indicates v2 test for
trends; c indicates Fisher0 s Exact Test; d indicates Mann–Whitney Test
SD standard deviation
* Indicates p \ .05; p corrected for multiple testing analysis (ABC: p \ .010, MOAS: p \ .0125)

to hearing or visual deficits and movement disorders
including for example spasticity, dystonia, cerebral palsy,
or extrapyramidal movement disorders. Seizure disorders
were assessed and documented when present within the
past 10 years. Mental disorders were diagnosed based on
the ICD-10 diagnostic criteria and grouped according to
the second variable, i.e., dependency disorders (F1x.x),
schizophrenia (F2x.x), mood disorders (F3x.x), neurotic,
stress-related and somatoform disorders (F4x.x), person-
ality disorders (F6x.x), and ASD (F8x.x). The single indi-
vidual could have no, only one, or more than one mental or
neurological disorder.
Diagnosing ASD
Clinical ICD-10 diagnoses for autism and atypical autism
(F84.0/F84.1) were based on all available information from
the current and past medical history, a comprehensive
psychiatric and physical examination, a video-based
behavior analysis, and standardized psychodiagnostic
assessments such as the Social Communication Question-
naire (SCQ) and the Scale for Pervasive Developmental
Disorders in Mentally Retarded Persons (PDD-MRS;
Kraijer and Melchers 2003; Rutter et al. 2001). The SCQ is
a categorical scale consisting of 40 items designed to
screen for ASD in children and adolescents (4–18 years).
The PDD-MRS is a diagnostic interview conducted by a
trained psychologist with a professional caregiver evalu-
ating autistic and problem behaviors of the patient in situ-
ations of daily living. It consists of 12 categorical items,
some of which are weighted. After these screening
assessments were completed, a multidisciplinary case
conference was conducted that consisted of at least one
psychiatrist and one psychologist. In case of a concordant
appraisal for or against ASD, no more assessments were
applied. In case of diagnostic uncertainty, the Autism
Diagnostic Observation Schedule (ADOS; n = 48) and/or
the Autism Diagnostic Interview-R (ADI-R; n = 24) were
conducted (Lord et al. 1989, 1994, 2000). The ADOS is a
semi-structured observational instrument assessing social
and communicative abilities in individuals suspected of
having ASD (Lord et al. 1989, 2000). The ADI-R is a semi-
structured parental interview assessing social reciprocity,
communication and restrictive, repetitive behaviors and
interests over a lifetime (Lord et al. 1994). Recently, the
validity of these measures has been demonstrated in the
adult ID population (Sappok et al. 2013). The final diag-
nostic classification was assigned by a second consensus
conference.
Test Materials
Assessment of ED
The SAED by Dosen (1997) is an interview conducted by a
psychologist or psychiatrist trained in developmental psy-
chology with a close caregiver after remission of the acute
exacerbation of the psychiatric illness. The SAED evalu-
ates the achieved developmental level in 10 basic aspects
of ED:
1. Dealing with the own body
2. Interaction with a caregiver
3. Experience of the self
4. Object permanence
5. Anxiety
6. Interaction with peers
7. Handling of material objects
8. Verbal communication
9. Affect differentiation
10. Aggression regulation
According to the 5 possible developmental levels (cf.
Table 1), values from 1 to 5 can be scored on this ordinal-
scaled measure. Certain statements of observed behavior
that are typical for the developmental level guide the
interview. Statements in level one (adaptation) of the first

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J Autism Dev Disord (2014) 44:786–800
domain (dealing with his/her own body) are for example: 1.
engages with own body (observing, playing, sucking,
masturbating, picking, and injuring.), 2. moves in a ste-
reotypical manner (engages in particular movements in
the same manner repetitively), and 3. passive (shows no
initiative). The behaviors of a person that can be observed
most often mark the developmental level at which the
person is functioning in a certain domain. In this study,
the overall judgment of the developmental level was
according to the mean level reached over the 10 different
domains. The SAED interview lasted approximately
20–30 min. The scheme has shown adequate inter-rater
reliability (kappa = .75), internal consistency (Cronbach’s
alpha = .96) and concurrent validity with the Vineland
Adaptive Behavior Scales (r = .51, p \ .002; La Malfa
et al. 2009).
Severity of ID
Participants were grouped as having a mild, moderate, or
severe/profound ID according to the current/latest medical
record. In accordance with the ICD-10, the IQ cut points
used were 50–70 (mild ID), 35–50 (moderate ID), and
below 35 (severe to profound ID). Assignment was based
upon the results of the Disability Assessment Schedule
(DAS) in 132 clients (Holmes et al. 1982; Meins and
Süssmann 1993). The DAS proofed high reliability and
good validity results as it highly correlated with the Col-
oured Progressive Matrices (r = .75) and the Columbia
Mental Maturity Scale (r = .77) (Holmes et al. 1982;
Meins and Süssmann 1993). In the absence of a DAS,
clients were categorized according to their daily living and
communication abilities by a physician experienced in the
field of ID. In case of uncertainties in ID assignments,
structured IQ assessment was applied in selected patients,
e.g., the Coloured Progressive Matrices, the Kaufmann-
Assessment-Batteries for Children, the Snijders-Omen-
Nonverbal Intelligence Test, or the Wechsler-Intelligence
Test for Adults.
Assessment of Challenging Behavior
Challenging behavior was measured by the ABC, a widely
used and validated instrument for assessing behavior
problems in children and adults with ID, during the first
assessments after hospital referral (Aman et al. 1985). The
ABC is a rating scale with 58 items rated on a four-point
ordinal scale. It is completed by a caregiver who knows the
target individual well. It has demonstrated good discrimi-
nant and convergent validity and test–retest reliability
(r = .96 to .99), but low inter-rater reliability (r = .55 to
.69). It consists of five subscales (irritability, lethargy,
stereotyped behavior, hyperactivity, and inappropriate
791
speech) that have been found to have high internal con-
sistency with Cronbach’s alpha ranging from .86 to .94.
Assessment of Aggression
The secondary outcome measure to quantify aggression
was the MOAS, an instrument often used and validated in
individuals with psychiatric illnesses (Knoedler 1989;
Yudofsky et al. 1986). Oliver et al. (2007) showed good
reliability results in individuals with ID (interclass corre-
lation coefficient = 0.93). It consists of 4 items (verbal
aggression, aggression to objects, self, and others) on a
five-point ordinal scale. It was applied during the first
assessment after admission to hospital.
Assessment of Outcome Variables
Living arrangements and employment were evaluated. The
living situation was categorized as either ‘alone’, ‘living
with family’, or ‘residential home’. With respect to
employment, grouping possibilities were ‘unemployment’,
‘school’, ‘rehab program’, ‘sheltered work’, or ‘retirement’.
Data Analysis
(A) First, a correlation analysis (Pearson’s r) of all possible
predictors including several mental and neurological
disorders, age, gender, and level of ID and ED with the
ABC and MOAS total scores and subscales was run.
The multiple testing problem connected with simulta-
neous testing of 14 variables was corrected by the
Bonferroni method (p \ .05/14 = .004). Secondly,
multivariate linear regression analysis was computed
for the ABC and MOAS total and subscale scores with
forced entry of all variables for which substantial cor-
relations have been found. Finally, the analysis was
rerun to get an insight in the added variance of each
factor. In Model 1 relevant baseline variables were
included and each correlating factor of interest was
added in a separate Model, respectively.
(B) First, multivariate logistic regression analysis was
computed for living and working situations, which
provided at least 5 % of individuals in each group, i.e.,
living with parents, living in a residential home,
unemployment, rehab program, or sheltered work.
The following predictors were included: Mental and
neurological disorders, medication, ABC and MOAS
total scores, severity of ID and level of ED, age and
gender. Second, we computed a multivariate logistic
regression analysis for medication (dependent variable)
and several mental disorders (independent variables).
123
 792

123
Table 3 Correlation analysis of possible predictors for challenging and aggressive behaviors
ABC MOAS
ABC total Irritability Lethargy Stereotypy Hyper- Inappropr- MOAS total Aggression Aggression Aggression Aggression
activity iate speech verbal objects self others
r p r p r p r p r p r p r p r p r p r p r p

Age 2.25 .0005 2.24 .001 n.s. n.s. n.s. n.s. 2.30 .0005 n.s. n.s. 2.25 .0005 n.s. n.s. -.20 .005 2.21 .003 2.24 .001
Male gender n.s. n.s. n.s. n.s. .18 .011 .21 .003 n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. -.15 .037 n.s. n.s.
Severity of ID .16 .027 n.s. n.s. n.s. n.s. .25 .0005 .22 .002 2.20 .004 n.s. n.s. n.s. n.s. n.s. n.s. .18 .011 n.s. n.s.
Level of ED 2.28 .0005 2.20 .004 2.22 .002 2.30 .0005 2.28 .0005 .21 .003 n.s. n.s. .22 .002 n.s. n.s. 2.36 .0005 n.s. n.s.
Hearing deficits n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. -.14 .047
Visual deficits n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s.
Movement disorder n.s. n.s. n.s. n.s. n.s. n.s. -.14 .048 n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s.
Seizure disorder n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s.
Dependency disorders n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. .15 .039 .19 .008
Schizophrenia n.s. n.s. n.s. n.s. .17 .018 .15 .032 n.s. n.s. n.s. n.s. n.s. n.s. -.19 .007 n.s. n.s. n.s. n.s. n.s. n.s.
Mood disorders n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. .17 .02 n.s. n.s. n.s. n.s. n.s. n.s.
Neurotic disorders n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s.
(F4x.x)
Personality disorders n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. .20 .004 n.s. n.s. n.s. n.s. n.s. n.s.
ASD .32 .0005 .18 .009 .29 .0005 .36 .0005 .22 .0001 n.s. n.s. n.s. n.s. n.s. n.s. n.s. n.s. .22 .002 n.s. n.s.
n.s. = no significant correlation; bold letters: p \ .05 adjusted for Bonferroni: .05/14 = .004
J Autism Dev Disord (2014) 44:786–800
J Autism Dev Disord (2014) 44:786–800 793

The study population was described in detail. The differences
between the ASD and non-ASD groups with respect to
demographics and clinical characteristics were evaluated
using v2 tests, t-tests, and Fisher0 s Exact Test, where appro-
priate. ASD/non-ASD group differences for the ABC and
MOAS sum scores and various subscales were evaluated
using a Mann–Whitney test. The multiple testing problem
connected with simultaneous testing of the five (ABC) or four
(MOAS) items was corrected by the Bonferroni method
(p \ .05/5 = .01 and p \ .05/4 = .0125, respectively).
Results
Predictors for Challenging and Aggressive Behaviors
Correlation Analysis of Possible Predictors
for Challenging or Aggressive Behaviors
All possible predictors for challenging or aggressive
behaviors including several mental and neurological
disorders, levels of functioning (ID and ED), and baseline
variables (age, gender) were included in a Pearson’s r cor-
relation analysis with the ABC and MOAS total and sub-
scale scores. The results are shown in Table 3.
With respect to the mental and neurological disorders
studied, ASD revealed associations with the ABC sum
score and various subscales, e.g., lethargy, stereotypy, and
hyperactivity. Moreover, ASD correlated with aggression
to the self. Beside from ASD, only personality disorders
showed a correlation with the MOAS subscale ‘verbal
aggression’. Regarding the level of functioning, ED dis-
played several negative associations with the ABC total
and most of its subscales and ‘aggression to self’ indicating
more severe problem behaviors at lower levels of ED. The
ABC subscale ‘inappropriate speech’ and the MOAS sub-
scale ‘verbal aggression’, however, showed an inverse
pattern. Thus, individuals with higher levels of ED exhib-
ited more verbal challenging and aggressive behaviors.
Correspondingly, the severity of ID was negatively asso-
ciated with ‘inappropriate speech’. Additionally, ‘hyper-
activity’ and ‘stereotypy’ were strongly correlating with

Table 4 Regression analysis predicting the effect of correlating factors on challenging behaviors and aggression
Dependent variable Predictor Multivariate regression—forced entry Regression analysis controlled for age/gender where
necessary
R2 b [95 % CI] p R2 b [95 % CI] p

ABC total Age .17 -0.46 [-0.73; -0.19] .001 .06 -0.52 [-0.80; -0.23] .0005
ED -3.84 [-7.55; -0.14] .042 .12 -6.56 [-9.97; -3.15] .0005
ASD 12.71 [5.12; 20.30] .001 .15 16.17 [9.29; 23.04] .0005
Irritability Age .09 -0.16 [-0.27; -0.06] .001 .06 -0.18 [-0.28; -0.08] .001
ED -1.63 [-2.38; -0.39] .01 .09 -1.63 [-2.87; -0.39] .01
Lethargy ASD .10 4.37 [1.67; 7.08] .002 .08 5.31 [2.87, 7.74] .0005
ED -1.03 [-2.34, 0.29] n.s. .05 -1.96 [-3.17; -0.76] .002
Stereotypy Males .20 1.89 [0.60; 3.19] .004 .04 2.13 [0.74; 3.53] .003
ASD 2.58 [1.22; 3.93] \.001 .16 3.33 [2.09; 4.56] .0005
ED -0.49 [-1.27; 0.30] n.s. .13 -1.39 [-2.00; -0.78] .0005
ID 0.84 [-0.18; 1.86] n.s. .11 1.67 [0.81; 2.53] .0005
Hyperactivity Age .17 -0.21 [-0.31; -0.11] .0005 .09 -0.23 [-0.33, -0.13] .0005
ASD 2.44 [-0.35; 5.23] n.s. .13 4.04 [1.49; 6.59] .002
ED -1.16 [-2.80; 0.49] n.s. .15 -2.34 [-3.58; -1.11] .0005
ID 1.56 [-0.55; 3.67] n.s. .14 2.92 [1.19; 4.64] .001
Inappropriate speech ED .05 0.43 [-0.10; 0.96] n.s. .04 0.65 [0.22; 1.09] .003
ID -0.53 [-1.28; 0.21] n.s. .04 -0.89 [-1.49; -0.28] .004
MOAS total Age .06 -0.52 [-0.8; -0.24] .0005
Aggression: verbal ED .07 0.21 [0.04; 0.38] .014 .05 0.26 [0.10; 0.43] .002
Personality disorders 0.82 [0.09; 1.54] .027 .04 1.05 [0.34; 1.76] .004
Aggression: self Age .16 -0.02 [-0.03; 0] .013 .04 -0.12 [-0.03; -0.01] .003
ASD 0.18 [-0.17, 0.52] n.s. .09 0.49 [0.17; 0.80] .003
ED -0.34 [-0.51, -0.18] .0005 .15 -0.38 [-0.53, -0.23] .0005
Aggression: others Age .06 -0.02 [-0.04; -0.01] .001
n.s. = no significant correlation; c.f. = controlled for; bold letters: p \ .05 in multivariate regression analysis

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794 J Autism Dev Disord (2014) 44:786–800

ID. Strong correlations could also be seen for ‘age’ with the higher levels of ED were both independent predictors for
ABC and MOAS total score and several of their subscales ‘verbal aggression’ (cf. Table 3).
(c.f. Table 3).

Regression Analysis for Several Correlating Factors
on Challenging Behaviors and Aggression
In a next step, several potential predictors that showed high
correlations for challenging or aggressive behaviors were
examined by multivariate regression analysis (c.f. Table 4).
The most important predictors for overall challenging
behaviors as measured by the ABC total score were ASD,
lower levels of ED, and age. A second regression analysis
for ED and ASD, controlled for ‘age’, revealed an added
variance of 6 and 9 %, respectively. The most important
predictor for overall aggression, aggression to others, and
hyperactivity was age, explaining 6, 6, and 9 % of vari-
ance. High scores for ‘irritability’ and ‘aggression to self’
depended on both, younger chronological ages and lower
levels of ED. ASD was the most important predictor for
‘lethargy’ and ‘stereotypy’ explaining 8 and 12 % of var-
iance. Interestingly, independent from ASD, also male
gender predicted stereotypic behaviors. Corresponding
with the correlation analysis, personality disorders and
Predictors for Outcome Variables
Regression Analysis for Living and Working Situations
Table 5 displays all predictors for the living and working
situations assessed in our study as indicated by multivariate
regression analysis.
Low levels of ED were predictive for unemployment
and lower rates of a sheltered work. Moreover, individuals
with a lower ED more often lived with their parents instead
of a residential home. Unemployment was not only
depending on ED, also higher scores of challenging
behavior as indicated by the ABC total, presence of per-
sonality disorders, and absence of an affective disorder
predicted unemployment in our clinical sample. The
severity of ID was the most important predictor for par-
ticipation in a rehab program. Individuals of older ages and
higher rates of aggressive behaviors (MOAS total score)
more often lived in a residential home and less often with
their parents.

Table 5 Multivariate logistic

Dependent variable Predictor Multivariate regression—forced entry
regression analyses for living
and working situations and R2a OR [95 % CI] p
medication usage
Unemployment Mood disorders .36 .19 [0.05; 0.71] .013
Personality disorders 11.95 [1.71; 83.4] .012
ABC total score 1.02 [1; 1.04] .04
Level of ED .37 [.21; .68] .001
Rehab program Severity of ID .26 1.9 [1.02; 3.55] .045
Sheltered work Level of ED .45 2.29 [1.36; 3.88] .002
Living with parents Age .54 0.80 [0.71; 0.90] .0005
Mood disorders 0.11 [0.01; 0.80] .03
Movement disorder 15.96 [2.24; 113.56] .006
Level of ED 0.35 [0.13; 0.91] .032
MOAS total score 0.71 [0.55; 0.91] .006
Residential home Age .46 1.16 [1.08; 1.25] .0005
Movement disorder 0.12 [0.02; 0.69] .017
Level of ED 2.81 [1.23; 6.47] .015
Severity of ID 3.80 [1.15; 12.52] .028
MOAS total score 1.38 [1.11; 1.70] .003
Antipsychotics-high potency Schizophrenia .21 7.48 [3.02; 18.54] .0005
ASD 1.99 [1.04; 3.81] .037
Antipsychotics-low potency Schizophrenia .16 4.28 [2.04; 8.97] .0005
Antidepressants Mood disorders .24 7.40 [3.24; 17.00] .0005
Anticonvulsive drugs Mood disorders .05 2.19 [1.14; 4.21] .019
Benzodiazepines Dependency disorders .13 7.41 [2.00; 27.49] .003
OR odd’s ratio
a Schizophrenia 2.55 [1.02; 6.38] .045
Nagelkerkes R2

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J Autism Dev Disord (2014) 44:786–800
Regression Analysis for Medication Usage
As can be seen in Table 2, the prevalence of schizophrenia
and prescriptions for antipsychotic drugs were significantly
increased in the ASD sample. Accordingly, multivariate
logistic regression analysis revealed that both, schizo-
phrenia and ASD were associated with the intake of high
potency antipsychotic drugs (c.f. Table 5). Univariate
regression analysis showed an explained variance for
antipsychotic drug usage of 17 % (OR 7.2) for schizo-
phrenia and 6 % (OR 2.5) for ASD. Low potency anti-
psychotics were only associated with schizophrenia, while
antidepressants and anticonvulsive drugs were associated
with affective disorders. Benzodiazepines were predicted
by schizophrenia and dependency disorders explaining 4 %
(OR 2.4) and 7 % (OR 6.3) of the total variance (univariate
regression analysis), respectively (c.f. Table 5).
Discussion
This study aimed to examine the impact of various mental
and neurological disorders, the level of ED, the severity of
ID, age, and gender on (A) challenging and aggressive
behavior and (B) certain outcome parameters in a repre-
sentative clinical sample of adults with ID. ASD was the
only mental disorder predicting overall challenging
behavior, in particular ‘lethargy’ and ‘stereotypic behav-
ior’. Personality disorders were associated with ‘verbal
aggression’. With regard to the level of functioning, a
lower level of ED was the major factor predicting chal-
lenging behavior (ABC), in particular overall challenging
behavior (ABC total) and ‘irritability’, and also aggression
(MOAS), in particular less ‘verbal aggression’ and more
‘aggression to self’. Age war inversely associated with
overall challenging and aggressive behaviors and most of
the subscales, while male gender was predictive for ster-
eotypic behaviors. (B) Unemployment was predicted by
high rates of challenging behaviors, low levels of ED, and
presence of personality disorders. Attendance at a sheltered
working place was solely depending on higher levels of
ED. Individuals showing aggressive behaviors more often
lived in a residential home and less likely lived with their
parents. Antipsychotic drug usage was associated not only
with schizophrenia, but also with ASD.
Predictors for Challenging Behaviors
Overall challenging behaviors as measured with the ABC
total score was predicted by the presence of ASD, low
levels of ED and younger ages. Our study confirms and
expands previous research conducted by McCarthy et al.
(2010) who showed that challenging behavior is increased
795
in adults with ASD & ID compared to adults with ID only.
To determine, what type of challenging behavior was
specific for ASD, we analyzed the ABC subscales sepa-
rately. Correlation analysis of the ABC subscales revealed
an association of ASD with the subscales ‘irritability’,
‘hyperactivity’, ‘lethargy’, and ‘stereotypic behavior’.
After controlling for several other correlating factors and
age, ASD was still associated with elevated values in the
ABC total score and the subscales ‘lethargy’ and ‘stereo-
typy’. High levels of stereotypic behaviors in individuals
with ASD/ID combined versus ID only is a consistent
finding in studies evaluating patterns of challenging
behavior (Hill and Furniss 2006; Kraijer 2000; Matson and
Rivet 2008; McTiernan et al. 2011). As stereotypic
behavior is one of the core features of ASD, this result is
not surprising. Thus, factors other than the level of func-
tioning may cause stereotypy, e.g., differences in sensory
processing or increased anxiety levels (Joosten and Bundy
2010). In summary, ASD is the major factor leading to
stereotypical and lethargic challenging behavior. Treatment
of social interaction and communication skills may be
supportive in the reduction of these behaviors.
The level of ED predicted overall challenging behaviors
and showed associations with all 5 ABC subscales and
‘aggression to self’. After controlling for other correlating
factors, delays in ED predicted high levels of the overall
challenging behavior, ‘irritability’ and ‘aggression to self’
and lower values of ‘verbal aggression’. This is supported
by studies concerning adaptive behavior, which is highly
correlated with the level of ED (La Malfa et al. 2009),
because it is an important predictor for the severity of
challenging behavior (Matson et al. 2009a, b; Totsika et al.
2010). According to the developmental approach, the
reduction in adaptive behaviors may be caused by lower
levels of ED. Moreover, co-morbidity of ASD and ID is
associated with less secure bonding (Rutgers et al. 2004).
Secure attachment is a developmental achievement attained
around the age of 3 years, which may not be reached in
case of developmental delay. Using the developmental
approach, the increase in problem behaviors due to
impaired attachment may be caused by the delay in ED (De
Schipper and Schuengel 2010; Loeber et al. 2009; Robins
and Price 1991). Analyzing the problem behavior resulting
from attachment disorder, De Schipper and Schuengel
(2010) also described high values of ‘irritability’, which
further supports our findings on this subscale. In a longi-
tudinal study, emotional difficulties at the age of 2 years
predicted specific behavioral problems at the age of 5 years
(Treyvaud et al. 2012). In summary, various surveys
revealed coherence between emotional developmental
delays and behavioral problems. However, this is not a
one-way relationship, as an individual, who is temporar-
ily experiencing behavioral problem will get a lower
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796
SAED-level than the level he is normally functioning at
(data not shown), implying that CB has an influence on the
ED level as well.
The severity of ID correlated with the ABC total score,
‘hyperactivity’, ‘stereotypy’, and ‘aggression to self’.
Multivariate regression analysis, however, revealed that
factors such as age, presence of ASD, and the level of ED
are more important predictors for these behaviors than the
severity of ID. ‘Inappropriate Speech’ was negatively
correlated with severity of ID and inversely correlated with
level of ED. With increasing cognitive impairment and
lower emotional maturity, verbal abilities and thus chal-
lenging behavior with ‘inappropriate speech’ decreased.
According to our study results, a male gender was pre-
dictive for ‘stereotypic behaviors’ even when controlled for
other correlating factors. ‘Overall challenging and aggres-
sive behavior’ and several subscales such as ‘irritability’,
‘hyperactivity’, and ‘aggression to the self and to others’
decreased with increasing age. This promising result for
many individuals, their families and carers confirms and
expands previous research to adulthood (De Bildt et al.
2005; Maskey et al. 2013). Age is the most important
predictor for ‘hyperactivity’, explaining 9 % of its vari-
ance. ED, ID, and ASD add another 6, 5, and 4 % of the
total variance, respectively. The impact of ASD and ID on
‘hyperactivity’ has been described earlier (Totsika et al.
2011) and our study results add the relevance of the level of
ED.
Predictors for Aggression
A younger age was the only predictor for overall aggres-
sive behaviors, neither any mental disorder nor levels of
ED or ID led to an increase in the total MOAS score. This
is consistent with other studies conducted in children and
young adults with ASD (Baghdadli et al. 2003; Kraijer
2000; McTiernan et al. 2011), but converse findings also
have been described (McClintock et al. 2003). Concerning
the MOAS subscales, an association of age, the level of ED
and—to a lesser extend—ASD with ‘aggression to the
self’, personality disorders with ‘verbal aggression’, and
age with ‘aggression to others’ could be found. Self-injury
affects physical well-being, e.g., causing secondary infec-
tions, malformations, or sensory impairments, tends to
persist throughout life, and is an important affliction for
caregivers (Emerson et al. 2001). Self-injurious behavior is
thus a major impairment in affected individuals and ade-
quate treatment is critical. The increase in self-injurious
behavior in the ASD population, especially in those with
additional ID, and in individuals with ID alone have been
reported previously (Baghdadli et al. 2003; McClintock
et al. 2003; McTiernan et al. 2011). Positive associations
have been described between self-injurious behavior and
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J Autism Dev Disord (2014) 44:786–800
the severity of ASD characteristics, impulsivity, low verbal
and cognitive abilities, hyperactivity, and negative affect
(Matson and Rivet 2008; Richards et al. 2012). The fun-
damental importance of the delays in ED found in our
study, however, may extend the understanding of mecha-
nisms leading to self-injury and thereby may offer a further
approach for treatment.
Outcome Variables
Lower levels of ED and higher levels of challenging and
aggressive behaviors were important variables for the liv-
ing and working situation of an individual. Attendance at a
‘sheltered work’ was depending on higher levels of ED and
conversely, ‘unemployment’ was predicted by lower levels
of ED. Moreover, ‘unemployment’ increased with higher
ABC total scores and presence of personality disorders.
Regarding the examined variables for the living situation,
overall aggressive behavior and the level of ED were
crucial variables: Individuals with high MOAS total scores
more often lived in residential homes and less often lived
with their parents, likely owing to the family burden of
aggressive behavior. Interestingly, individuals with lower
chronological and emotional ages more often lived with
their families and less often lived in residential homes,
while individuals with lower levels of ID more often lived
in a residential home. Once more, this finding supports the
importance of measuring the emotional developmental
level and not to deduce it from the severity of ID.
A multivariate regression analysis showed that—inde-
pendently form schizophrenia—ASD predicted antipsy-
chotic drug usage, which agrees with previous studies
(Tsakanikos et al. 2007; Witwer and Lecavalier 2005).
Accordingly, the presence of ASD associated challenging
behavior may induce physicians to prescribe antipsychotics
in the absence of schizophrenia. Furthermore, our study
revealed a significant decrease in disabling motor disorders
in the ASD sample compared to the non-ASD sample with
implications for the living situation. Interestingly, Klin
et al. (1992) found a similar pattern on the motor domain of
the Vineland scale. This issue requires further clarification.
Clinical Impact
The high incidence of challenging behaviors presents a barrier
to attendance in designated programs (Holden and Gitlesen
2006). Accordingly, De Bildt et al. (2005) concluded adaptive
functioning was the most important factor in predicting the
level of education in individuals with ID. Assessment and
treatment of challenging behavior in the ID population is
complex and requires a multifaceted approach, especially as
psychopharmacology has not revealed an evidence-based
treatment option (Brylewski and Duggan 2004). Over the past
J Autism Dev Disord (2014) 44:786–800
decades, behavioral based assessments, such as functional
analysis (Didden et al. 1999; Grey and Hastings 2005), and
treatments, such as applied behavioral analysis (Reichow
et al. 2012; Warren et al. 2011), were the most favored and
best-studied methods. However, these programs are time-
consuming with limited availability, and funding remains a
challenge for many families. Moreover, despite gains in
cognitive, verbal, and adaptive skills, treatments targeting
behavioral and social skill have only a limited effect on daily
life skills, behavioral and emotional problems (Begeer et al.
2011; Matson and Rivet 2008; McTiernan et al. 2011; Mur-
phy et al. 2009).
Uncovering developmental mechanisms may be particu-
larly useful to prevent behavioral or mental health problems.
Loeber et al. (1993) demonstrated transformation of problem
behavior across developmental periods, e.g., from opposi-
tional behavior to conduct problems to antisocial personality
disorder. This suggests that different levels of development
may be associated with certain types of psychopathology.
Janssen et al. (2002) provided with the ‘stress-attachment
model’, a promising developmentally based explanatory
framework of challenging behavior among people with ID.
Within this developmental understanding of maladaptive
behavior, the impact for therapy has been shown in a number
of studies (Sappok et al. 2012a, b; Schuengel et al. 2009;
Smith et al. 2008). These developmentally derived interven-
tions may lead to changes in emotional skills and subsequent
improvements in pro-social behavior and peer relationships,
even in autistic individuals (Bergmann et al. 2011; Hofer et al.
2009; Schumacher and Calvet 2008). Analysis of etiological
factors should not be driven by linear causal thinking, but by a
multifaceted approach. Thus, an increasing number of inter-
vention programs integrate applied behavior analysis with
developmental and relationship-based methods (Eapen et al.
2013; Freitag et al. 2012) and report promising results with
respect to adaptive skills, cognition and symptom severity.
To conclude, the assessment and recognition of the level
of ED may bring an additional perspective to the mecha-
nisms leading to problem behaviors in the ID population.
The developmental approach might serve as a diagnostic
aid for services supporting people with ID and lead to a
better understanding of the problem behaviors shown by
the individual. Subsequently, better-tailored treatment and
teaching options may arise. Considering the basic emo-
tional needs connected with a certain level of ED may
increase well-being of the affected individual, stimulate a
further development of personality and result in acquisition
of functional life skills.
Limitations
A number of limitations need to be considered when
interpreting our results. Due to the retrospective study
797
design of a clinical sample, the appraisal of the severity of
ID was taken from the current/latest medical record. Psy-
chometric based ID assessment was available in many, but
not in all individuals, which need to be considered when
interpreting the results. Moreover, only a limited range of
variables could be assessed in most participants; therefore
important factors, such as the type of non-pharmacological
treatment, life events, caregiver’s attitude, etc., were not
evaluated in the study. When interpreting relationships
between the different predictors and the severity of chal-
lenging behavior, the interaction effects formally accoun-
ted for only a small proportion of total variance. This may
be partially explained by the study design, as field studies
often have less than 20 % of the efficiency of optimal
experimental tests (McClelland and Judd 1993). Moreover,
the explained variance may be low due to the restricted
range of the predictors, as most were dichotomized or or-
dinally scaled ranging over 3 (severity of ID) to 5 (level of
ED) grades. Nevertheless, the low percentage of explained
variance suggests that other factors still need to be con-
sidered, for example behavioral phenotypes of certain
genetic disorders, (Down, Fragile X, or Prader-Willi syn-
drome; Loveland and Tunali-Kotoski 1998), and environ-
mental factors such as life events and social care (Hove and
Havik 2010). Recognition of the level of ED, however,
may extend and further improve the understanding of the
complex circumstances causing challenging behavior
among people with ID and may have an impact on more
tailored treatment options.
Conclusion
Aside from chronological age, presence of ASD and the
level of ED were the most important predictors for chal-
lenging and aggressive behaviors among people with ID
and have an impact on the living and working situation and
antipsychotic drug usage. Our study expands previous ASD
research to adulthood and adds the aspect of the overall
developmental level to the assessment of individuals with
severe problem behaviors. This detailed analysis of the
origins of behavioral disorders may suggest priority areas
for diagnostics and therapy, as these behaviors create
obstacles to learning and productive labor. ED may be
stimulated in individuals with ASD and ID to prevent or
reduce problem behaviors, develop social and communi-
cation skills, and provide the prerequisites for participation
in society and living a productive, satisfying life.
Acknowledgments We thank the foundation ‘‘von Bodelsch-
winghsche Stiftungen Bethel’’ for funding the study. Sven Bölte was
supported by the Swedish Research Council (Grant No. 523-2009-
7054). We thank the clinicians who helped in data collection. We
appreciate Manuel Heinrich for his thorough data search from patient
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798
charts, data entry, support in data analysis, and layout. Thanks to
Heika Kaiser who thoroughly performed the SAED, SCQ, PDD-
MRS, ADOS, and ADI-R evaluations. We appreciate the compre-
hensive elaboration of the reviewer as it substantially strengthened the
methodology and intelligibility of the study.
Conflict of interest Sven Bölte receives royalties for the German
version of the ADOS and ADI-R from Hans Huber Publishers.
Beyond that, the authors declare no conflicts of interest.
References
Aldao, A., & Nolen-Hoeksema, S. (2012). The influence of context on
the implementation of adaptive emotion regulation strategies.
Behavior Research and Therapy, 50, 493–501.
Aman, M. G., Singh, N. N., Stewart, A. W., & Field, C. J. (1985). The
Aberrant Behavior Checklist: A behavior rating scale for the
assessment of treatment effects. American Journal of Mental
Deficancy, 89, 485–491.
Baghdadli, A., Pascal, S., Grisi, S., & Aussilloux, C. (2003). Risk
factors for self-injurious behaviors among 222 young children
with autistic disorders. Journal of Intellectual Disability
Research, 47, 622–627.
Begeer, S., Gevers, C., Clifford, P., Verhoeve, M., Kat, K.,
Hoddenbach, E., et al. (2011). Theory of mind training in
children with autism: A randomized controlled trial. Journal of
Autism and Developmental Disorders, 41, 997–1006.
Begeer, S., Koot, H. M., Rieffe, C., Terwogt, M. M., & Stegge, H.
(2008). Emotional competence in children with autism: Diag-
nostic criteria and empirical evidence. Developmental Review,
28, 342–369.
Bergmann, T., Dziobek, I., Reimer, S., Schumacher, K., Diefenbach-
er, A., & Sappok, T. (2011). Jenseits des Dialogs—Bez-
iehungsqualität in der Musiktherapie bei Menschen mit
Autismus und Intelligenzminderung [Beyond dialogue—quality
of relationships in music therapy for people with autism and
intellectual disability]. Medizin für Menschen mit geistiger oder
mehrfacher Behinderung, 8, 14–20.
Bertin, E., & Striano, T. (2006). The still-face response in newborn, 1.
5-, and 3-month-old infants. Infant Behaviour Development, 29,
294–297.
Bhaumik, S., Tyrer, F. C., McGrother, C., & Ganghadaran, S. K.
(2008). Psychiatric service use and psychiatric disorders in
adults with intellectual disability. Journal of Intellectual Dis-
ability Research, 52, 986–995.
Bowlby, B. (1969). Attachment and loss. London: Hogarth Press.
Brylewski, J., & Duggan, L. (2004). Antipsychotic medication for
challenging behaviour in people with learning disability. Coch-
rane Database Systematic Review, 3, CD000377.
Ciarrochi, J., & Scott, C. (2006). The link between emotional
competence and well-being: A longitudinal study. British
Journal of Guidance & Counselling, 34, 231–243.
Cooper, S. A., Smiley, E., Morrison, J., Williamson, A., & Allan, L.
(2007). Mental ill-health in adults with intellectual disabilities:
Prevalence and associated factors. British Journal of Psychiatry,
190, 27–35.
Damasio, A. (2010). Self comes to mind. Amsterdam:
Wereldbibliotheek.
De Bildt, A., Sytema, S., Kraijer, D., Sparrow, S., & Minderaa, R.
(2005). Adaptive functioning and behaviour problems in relation
to level of education in children and adolescents with intellectual
disability. Journal of Intellectual Disability Research, 49,
672–681.
123
J Autism Dev Disord (2014) 44:786–800
De Schipper, J. C., & Schuengel, C. (2010). Attachment behaviour
towards support staff in young people with intellectual disabil-
ities: Associations with challenging behaviour. Journal of
Intellectual Disability Research, 54, 584–596.
Didden, R., Duker, P. C., & Korzilius, H. (1999). Meta-analytic study
on treatment effectiveness for problem behaviors with individ-
uals who have mental retardation. American Journal of Mental
Retardation, 101, 387–399.
Dosen, A. (1997). Psychische Störungen bei geistig behinderten
Menschen. Stuttgart: Gustav Fischer Verlag.
Dosen, A. (2005). Applying the developmental perspective in the
psychiatric assessment and diagnosis of persons with intellectual
disability: Part I-assessment. Journal of Intellectual Disability
Research, 49, 1–8.
Eapen, V., Črnčec, R., & Walter, A. (2013). Clinical outcomes of an
early intervention program for preschool children with autism
spectrum disorder in a community group setting. BMC Pediat-
rics, 13, 3.
Emerson, E., Kiernan, C., Alborz, A., Reeves, D., Mason, H.,
Swarbrick, R., et al. (2001). Predicting the persistence of severe
self injurious behavior. Research in Developmental Disabilities,
22, 67–75.
Emerson, E., Kiernan, C., Turner, S., Hatton, C., & Alborz, A. (2000).
Psychiatric symptoms in adults with learning disability and
challenging behavior. The British Journal of Psychiatry, 177,
452–456.
Esbensen, A. J., Greenberg, J. S., Seltzer, M. M., & Aman, M. G.
(2009). A longitudinal investigation of psychotropic and non-
psychotropic medication use among adolescents and adults with
autism spectrum disorders. Journal of Autism and Developmen-
tal Disorders, 39, 1339–1349.
Felce, D., Kerr, M., & Hastings, R. P. (2009). A general practice-
based study of the relationship between indicators of mental
illness and challenging behaviour among adults with intellectual
disabilities. Journal of Intellectual Disability Research, 53,
243–254.
Freitag, C. M., Feineis-Matthews, S., Valerian, J., Teufel, K., &
Wilker, C. (2012). The Frankfurt early intervention program
FFIP for preschool aged children with autism spectrum disorder:
A pilot study. Journal of Neural Transmission, 119, 1011–1021.
Greenspan, S. (1979). Social intelligence in the retarded. In N.
R. Ellis (Ed.), Handbook of mental deficiency: Psychological
theory and research (pp. 483–531). Hillsdale, N.J.: Erlbaum.
Greenspan, S. (1997). Normal child development. In A. Freedman, H.
Kaplan, & B. Sadock (Eds.), Comprehensive textbook of
psychiatry (pp. 1102–1130). Baltimore: Williams & Wilkins.
Grey, I. M., & Hastings, R. P. (2005). Evidence-based practices in
intellectual disability and behaviour disorders. Current Opinion
in Psychiatry, 18, 469–475.
Hill, J., & Furniss, F. (2006). Patterns of emotional and behavioural
disturbance associated with autistic traits in young people with
severe intellectual disabilities and challenging behaviours.
Research in Developmental Disabilities, 27, 517–528.
Hobson, R. P. (1986). The autistic child’s appraisal of expressions of
emotion. Journal of Child Psychology and Psychiatry, 27,
321–342.
Hodapp, R., & Zigler, E. (1995). Past, present and future issues in the
developmental approach to mental retardation and developmen-
tal disabilities. In D. Cicchetti & D. Cohen (Eds.), Developmen-
tal psychopathology (pp. 299–331). New York: Wiley.
Hofer, S. M., Gray, K. M., Piccinin, A. M., Mackinnon, A.,
Bontempo, D. E., Einfeld, S. L., et al. (2009). Correlated and
coupled within-person change in emotional and behavioral
disturbance in individuals with intellectual disability. American
Journal of Intellectual and Developmental Disabilities, 114,
307–321.
J Autism Dev Disord (2014) 44:786–800
Holden, B., & Gitlesen, J. P. (2006). A total population study of
challenging behaviour in the county of Hedmark, Norway:
Prevalence, and risk markers. Research in Developmental
Disabilities, 27, 456–465.
Holmes, N., Shah, A., & Wing, L. (1982). The disability assessment
schedule: A brief screening device for use with the mentally
retarded. Psychological Medicine, 12, 879–890.
Hove, O., & Havik, O. E. (2010). Developmental level and other
factors associated with symptoms of mental disorders and
problem behaviour in adults with intellectual disabilities living
in the community. Social Psychiatry and Psychiatric Epidemi-
ology, 45, 105–113.
Izard, C. E., Youngstrom, E. A., Fine, S. E., Mostow, A. J.,
Trentacosta, C. J., & Campbell, J. (2006). Emotions and
developmental psychopathology. In D. Cicchetti & D.
J. Cohen (Eds.), Developmental psychopathology (pp.
244–292). New York: Wiley.
Jackson, M., & Tisak, M. S. (2001). Is prosocial behaviour a good
thing? Developmental changes in children’s evaluations of
helping, sharing, cooperating, and comforting. British Journal
of Developmental Psychology, 19, 349–367.
Janssen, C. G., Schuengel, C., & Stolk, J. (2002). Understanding
challenging behaviour in people with severe and profound
intellectual disability: A stress-attachment model. Journal of
Intellectual Disability Research, 46, 445–453.
Joosten, A. V., & Bundy, A. C. (2010). Sensory processing and
stereotypical and repetitive behaviour in children with autism
and intellectual disability. Australian Occupational Therapy
Journal, 57, 366–372.
Kasari, L. L., Jahromi, L. B., & Gulsrud, A. C. (2012). Emotional
development in children with developmental disabilities. In J.
A. Burack, R. M. Hodapp, & E. Zigler (Eds.), The oxford
handbook of intellectual disability and development (pp.
239–253). Cambridge, UK: Cambridge University Press.
Kasari, C., Sigman, M., Mundy, P., & Yirmiya, N. (1990). Affective
sharing in the context of joint attention interactions of normal,
autistic, and mentally retarded children. Journal of Autism and
Developmental Disorders, 20, 87–100.
Kernberg, O. (2012). The inseparable nature of love and aggression.
Washington, DC: American Psychiatric Publishing.
Klin, A., Volkmar, F. R., & Sparrow, S. S. (1992). Autistic social
dysfunction: Some limitations of the theory of mind hypothesis.
Journal of Child Psychology and Psychiatry, 33, 877–893.
Knoedler, D. W. (1989). The modified overt aggression scale.
American Journal of Psychiatry, 146, 1081–1082.
Kraijer, D. W. (2000). Review of adaptive behavior studies in
mentally retarded persons with autism/pervasive developmental
disorder. Journal of Autism and Developmental Disorders, 30,
39–47.
Kraijer, D., & Melchers, P. (2003). Skala zur Erfassung von
Autismusspektrumstörungen bei Minderbegabten (SEAS-M).
Frankfurt: Swets.
La Malfa, G., Lassi, S., Bertelli, M., Albertinti, G., & Dosen, A.
(2009). Emotional development and adaptive abilities in adults
with intellectual disability. A correlation study between the
scheme of appraisal of emotional development (SAED) and
Vineland adaptive behavior scale (VABS). Research in Devel-
opmental Disabilities, 30, 1406–1412.
Loeber, R., Jeffrey, D. B., & Dustin, A. P. (2009). Development and
etiology of disruptive and delinquent behavior. Annual Review of
Clinical Psychology, 5, 291–310.
Loeber, R., Wung, P., Keenan, K., Giroux, B., Stouthamer-Loeber,
M., Van Kammen, W. B., et al. (1993). Developmental pathways
in disruptive child behavior. Development and Psychopathology,
5, 103–133.
799
Lord, C., Risi, S., Lambrecht, L., Cook, E. H., Jr, Leventhal, B. L.,
et al. (2000). The autism diagnostic observation schedule-
generic: A standard measure of social and communication
deficits associated with the spectrum of autism. Journal of
Autism and Developmental Disorders, 30, 205–223.
Lord, C., Rutter, M., Goode, S., Heemsbergen, J., Jordan, H., et al.
(1989). Autism diagnostic observation schedule: A standardized
observation of communicative and social behaviour. Journal of
Autism and Developmental Disorders, 19, 185–212.
Lord, C., Rutter, M., & Le Couteur, A. (1994). Autism diagnostic
interview revised: A revised version of a diagnostic interview for
caregivers of individuals with possible pervasive developmental
disorders. Journal of Autism and Developmental Disorders, 24,
659–685.
Lounds, J., Seltzer, M. M., Greenberg, J. S., & Shattuck, P. T. (2007).
Transition and change in adolescents and young adults with
autism: Longitudinal effects on maternal well-being. American
Journal on Mental Retardation, 112, 401–417.
Loveland, K., & Tunali-Kotoski, B. (1998). Development of adaptive
behavior in persons with mental retardation. In J. A. Burack, R.
M. Hodapp, & E. Zigler (Eds.), Handbook of mental retardation
and development (pp. 521–541). Cambridge, UK: Cambridge
University Press.
Mahler, M. S., Pine, F., & Bergman, A. (1975). The psychological
birth of the human infant. New York: Basic Books.
Maskey, M., Warnell, F., Parr, J. R., Le Couteur, A., & McConachie,
H. (2013). Emotional and behavioural problems in children with
autism spectrum disorder. Journal of Autism and Developmental
Disorders, 43, 851–859.
Matson, J. L., Dempsey, T., & Rivet, T. T. (2009a). The interrela-
tionships of psychopathology symptoms on social skills in adults
with autism or PDD-NOS and intellectual disability. Journal of
Developmental and Physical Disabilities, 21, 39–55.
Matson, J. L., Kozlowski, A. M., Worley, J. A., Shoemaker, M. E.,
Sipes, M., & Horovitz, M. (2011). What is the evidence for
environmental causes of challenging behaviors in persons with
intellectual disabilities and autism spectrum disorders? Research
in Developmental Disabilities, 32, 693–698.
Matson, J. L., & Rivet, T. T. (2008). Characteristics of challenging
behaviours in adults with autistic disorder, PDD-NOS, and
intellectual disability. Journal of Intellectual Developmental
Disabilities, 33, 323–329.
Matson, J. L., Rivet, T. T., Fodstad, J. C., Dempsey, T., & Boisjoli, J.
A. (2009b). Examination of adaptive behaviour differences in
adults with autism spectrum disorders and intellectual disability.
Research in Developmental Disabilities, 30, 1317–1325.
McCarthy, J., Hemmings, C., Kravariti, E., Dworzynski, K., Holt, G.,
Bouras, N., et al. (2010). Challenging behavior and co-morbid
psychopathology in adults with intellectual disability and autism
spectrum disorders. Research in Developmental Disabilities, 31,
362–366.
McClelland, G. H., & Judd, C. M. (1993). Statistical difficulties of
detecting interactions and moderator effects. Psychological
Bulletin, 114, 376–390.
McClintock, K., Hall, S., & Oliver, C. (2003). Risk markers
associated with challenging behaviours in people with intellec-
tual disabilities: A meta-analytic study. Journal of Intellectual
Disability Research, 47, 405–416.
McTiernan, A., Leader, G., Healy, O., & Mannion, A. (2011).
Analysis of risk factors and early predictors of challenging
behavior for children with autism spectrum disorders. Research
in Autism Spectrum Disorders, 5, 1215–1222.
Meins, W., & Süssmann, D. (1993). Evaluation of an adaptive
behaviour classification for mentally retarded adults. Social
Psychiatry and Psychiatric Epidemiology, 28, 201–205.
123
800
Murphy, G. H., Beadle-Brown, J., Wing, L., Gould, J., Shah, A., &
Holmes, N. (2005). Chronicity of challenging behaviours in
people with severe intellectual disabilities and/or autism: A total
population sample. Journal of Autism and Developmental
Disorders, 35, 405–418.
Murphy, O., Healy, O., & Leader, G. (2009). Risk factors for
challenging behaviors among 157 children with autism spectrum
disorders in Ireland. Research in Autism Spectrum Disorders, 3,
474–482.
Oliver, P. C., Crawford, M. J., Rao, B., Reece, B., & Tyrer, P. (2007).
Modified Overt Aggression Scale (MOAS) for people with
intellectual disability and aggressive challenging behaviour: A
reliability study. Journal of Applied Research in Intellectual
Disabilities, 20, 368–372.
Pessoa, L. (2010). Emergent processes in cognitive-emotional inter-
actions. Dialogues Clinical Neuroscience, 12, 433–448.
Piaget, J. (1953). The child’s construction of reality. London:
Rotledge and Kegan Paul.
Reichow, B., Barton, E. E., Boyd, B. A., & Hume, K. (2012). Early
intensive behavioral intervention (EIBI) for young children with
autism spectrum disorders (ASD). Cochrane Database System-
atic Reviews, 17, 10:CD009260.
Rey, L., Extremera, N., Durán, A., & Ortiz-Tallo, M. (2012).
Subjective quality of life of people with intellectual disabilities:
The role of emotional competence on their subjective well-
being. Journal of Applied Research in Intellectual Disabilities,
11, doi: 10.1111/jar.12015.
Richards, C., Oliver, C., Nelson, L., & Moss, J. (2012). Self-injurious
behaviour in individuals with autism spectrum disorder and
intellectual disability. Journal of Intellectual Disability
Research, 56, 476–489.
Rieffe, C., Meerum Terwogt, M., & Cowan, R. (2005). Children’s
understanding of mental states as causes of emotions. Infant and
Child Development, 14, 259–272.
Robins, L., & Price, R. (1991). Adult disorders predicted by
childhood conduct problems: Results from the NIMH epidemi-
ological catchment area project. Psychiatry, 54, 116–132.
Rutgers, A. H., Bakermans-Kranenburg, M. J., van Ijzendoorn, M. H.,
& van Berckelaer-Onnes, I. A. (2004). Autism and attachment: A
meta-analytic review. Journal of Child Psychology and Psychi-
atry, 45, 1123–1134.
Rutter, M., Bailey, A., Berument, S. K., Lord, C., & Pickles, A.
(2001). Social Communication Questionnaire (SCQ). Los Ange-
les: Western Psychological Services.
Sappok, T., Bergmann, T., Kaiser, H., & Diefenbacher, A. (2010).
Autism in adults with mental retardation. Der Nervenarzt, 81,
1333–1345.
Sappok, T., Diefenbacher, A., Bergmann, T., Zepperitz, S., & Dosen,
A. (2012a). Emotional developmental disorders in individuals
with intellectual disabilities (ID): A case-control-study. Psychi-
atrische Praxis, 39, 1–11.
Sappok, T., Diefenbacher, A., Budczies, J., Schade, C., Grubich, C.,
Bergmann, T., et al. (2013). Diagnosing autism in a clinical
sample of adults with intellectual disabilities: How useful are the
ADOS and the ADI-R? Research Developmental Disabilities, 34,
1642–1655.
Sappok, T., Schade, C., Kaiser, H., Dosen, A., & Diefenbacher, A.
(2012b). The importance of a developmental approach in
123
View publication stats
J Autism Dev Disord (2014) 44:786–800
psychiatric assessment and treatment of adults with intellectual
disability. Fortschritte Neurologie und Psychiatrie, 80, 154–161.
Schuengel, C., Sterkenburg, P. S., Jeczynski, P., Janssen, C. G., &
Jongbloed, G. (2009). Supporting affect regulation in children
with multiple disabilities during psychotherapy: A multiple case
design study of therapeutic attachment. Journal of Consulting
and Clinical Psychology, 77, 291–301.
Schumacher, K., & Calvet, C. (2008). Synchronization—music
therapy with children on the autistic spectrum. Göttingen:
Vandenhoeck & Ruprecht.
Smith, L. E., Greenberg, J. S., Seltzer, M. M., & Hong, J. (2008).
Symptoms and behavior problems of adolescents and adults with
autism: Effects of mother–child relationship quality, warmth,
and praise. American Journal on Mental Retardation, 113,
384–402.
Sroufe, L. A. (2009). The concept of development in developmental
psychopathology. Child Developmental Perspectives, 3,
178–183.
Stern, D. N. (2007). Die Lebenserfahrung des Säuglings. Stuttgart:
Klett-Cotta.
Totsika, V., Felce, D., Kerr, M., & Hastings, R. P. (2010). Behavior
problems, psychiatric symptoms and quality of life for older adults
with intellectual disability with and without autism. Journal of
Autism and Developmental Disorders, 40, 1171–1178.
Totsika, V., Hastings, R. P., Emerson, E., Lancaster, G. A., &
Berridge, D. M. (2011). A population-based investigation of
behavioural and emotional problems and maternal mental health:
Associations with autism spectrum disorder and intellectual
disability. Journal of Child Psychology and Psychiatry, 52,
91–99.
Trevarthen, C. (1980). The foundations of intersubjectivity: Devel-
opment of interpersonal and co-operative understanding in
infants. In D. Olson (Ed.), The social foundations of language
and thought (pp. 316–342). New York: WW Norton.
Treyvaud, K., Doyle, L. W., Lee, K. J., Roberts, G., Lim, J., et al.
(2012). Social-emotional difficulties in very preterm and term
2 year olds predict specific social-emotional problems at the age
of 5 years. Journal of Pediatric Psychology, 37, 779–785.
Tsakanikos, E., Costello, H., Holt, G., Sturmey, P., & Bouras, N.
(2007). Behaviour management problems as predictors of
psychotropic medication and use of psychiatric services in
adults with autism. Journal of Autism and Developmental
Disorders, 37, 1080–1085.
Underwood, L., McCarthy, J., & Tsakanikos, E. (2010). Mental health
of adults with autism spectrum disorders and intellectual
disability. Current Opinion in Psychiatry, 23, 421–426.
Warren, Z., McPheeters, M. L., Sathe, N., Foss-Feig, J. H., Glasser,
A., & Veenstra-Vanderweele, J. (2011). A systematic review of
early intensive intervention for autism spectrum disorders.
Pediatrics, 127, e1303–e1311.
Witwer, A., & Lecavalier, L. (2005). Treatment incidence and
patterns in children and adolescents with autism spectrum
disorders. Journal of Child and Adolescent Psychopharmacol-
ogy, 15, 671–681.
Yudofsky, S. C., Silver, J. M., Jackson, W., Endicott, J., & Williams,
D. (1986). The Overt Aggression Scale for the objective rating of
verbal and physical aggression. American Journal of Psychiatry,
143, 35–39.