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Persistence of early emerging aberrant behavior in children with developmental disabilities
Research in Developmental Disabilities 26 (2005) 47–55
Persistence of early emerging aberrant behavior in children with developmental disabilities Vanessa A. Greena,*, Mark O’Reillyb, Jonathan Itchona, Jeff Sigafoosb a
Department of Educational Psychology, The University of Texas at Austin, 1 University Station, D5800, Austin, TX 78712-1290, USA b Department of Special Education, The University of Texas at Austin, 1 University Station, D5800, Austin, TX 78712-1290, USA Received 25 March 2004; received in revised form 28 June 2004; accepted 8 July 2004
Abstract This study examined the persistence of early emerging aberrant behavior in 13 preschool children with developmental disabilities. The severity of aberrant behavior was assessed every 6 months over a 3-year period. Teachers completed the assessments using the Aberrant Behavior Checklist [Aman, M. G., & Singh, N. N. (1986). Aberrant Behavior Checklist: Manual. East Aurora, NY: Slosson Educational Publications; (1994). Aberrant Behavior Checklist—Community. East Aurora, NY: Slosson Educational Publications]. Problem behaviors were present in all children at the beginning of the study. Nine of the 13 children entered the study with relatively high levels of aberrant behaviors that showed little change over the 3 years. These data suggest that aberrant behaviors often emerge early and can be highly persistent during the preschool years. Prevention would, therefore, seem to require home-based interventions that begin before 4 years of age. # 2004 Elsevier Ltd. All rights reserved. Keywords: Aberrant behavior; Developmental disabilities; Early intervention
* Corresponding author. E-mail address: [email protected] (V.A. Green). 0891-4222/$ – see front matter # 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.ridd.2004.07.003
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1. Introduction Aberrant behaviors, such as aggression, self-injury, property destruction, stereotyped movements, and extreme tantrums are highly prevalent in individuals with developmental disabilities (Emerson et al., 2001a). Given this high prevalence, it is not surprising that the treatment of aberrant behaviors is a major priority in developmental disability services. Advances in functional assessment methodology have lead to a range of new and improved interventions for the treatment of aberrant behaviors in individuals with developmental disabilities (Hastings & Brown, 2000). Relatively less research has focused on the prevention of aberrant behavior in young children with developmental disabilities (Sigafoos, Arthur, & O’Reilly, 2003). It is possible that a better understanding of the early development and longitudinal course of aberrant behaviors in young children with developmental disabilities may lead to improved prevention efforts. Along these lines, several studies have investigated the persistence of aberrant behaviors in individuals with developmental disabilities. Emerson et al. (2001b), for example, found that self-injurious behaviors were highly persistent over a 7-year period in a sample of 95 individuals receiving mental retardation services in the United Kingdom. Jones (1999) found that the stereotyped movements initially observed in eight adults with developmental disabilities were still evident 10 years later. In a more comprehensive study, Einfeld and his colleagues (Einfeld & Tonge, 1996; Einfeld, Tonge, & Rees, 2001; Einfeld, Tonge, Turner, Parmenter, & Smith, 1999; Tonge & Einfeld, 1991) tracked a sample of Australian children and adolescents with intellectual disabilities for 5 years to ascertain the prevalence of behavioral and emotional problems. They found that behavioral and emotional problems were highly prevalent (30%) and highly persistent in this sample, especially for individuals with certain types of disability syndromes. For example, behavioral and emotional problems were more common in individuals with Prader-Willi and Williams syndrome, when compared to individuals with Down syndrome (Einfeld et al., 1999). However, these previous studies have tended to focus on specific forms of aberrant behaviors (e.g., self-injury, stereotyped movements) and/or on older individuals. For example, the average age of the various syndrome groups in the Einfeld et al. (1999) study ranged from 9.5 to 17.2 years. It is therefore difficult to know if similar trends would be found in younger children. Longitudinal studies of younger children would, seem necessary to extend the current knowledge base. In addition to extending the current knowledge base to younger children, longitudinal assessments of aberrant behavior in young children with developmental disabilities may provide much needed data on the persistence of early emerging aberrant behaviors. Berkson and colleagues (Berkson, 2002; Berkson, Tupa, & Sherman, 2001) studied infants and toddlers with severe disabilities for signs of emerging stereotyped and selfinjurious behaviors. Their results suggest that these forms of aberrant behavior may emerge with the toddlers’ advancing motor skills and persist beyond 3 years of age. Murphy, Hall, Oliver, and Kissi-Debra (1999) noted, that ‘‘Very little is known about the early stages of self-injurious behavior (SIB) in young children with developmental disabilities . . .’’ (p. 149). They did, however, show that teachers might be able to identify early forms of self-injury in school-aged children with severe mental retardation and/or autism.
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Equally little is known about the early emergence and persistence of a range of other aberrant behaviors that are prevalent in children with developmental disabilities (Dunlap, Robbins, & Darrow, 1994). The lack of knowledge is addressed in the present study through a longitudinal study of preschool children who were considered to be at-risk for aberrant behaviors because of the severe nature of their disability (Schroeder, Tessel, Loupe, & Stodgell, 1997). If early and less serious aberrant behaviors can be identified in at-risk preschool children, then treatment can begin before these aberrant behaviors become more severe and firmly established. This in turn may improve treatment outcomes and may even help to prevent early and mild forms of aberrant behaviors from developing into more entrenched and serious challenging behaviors. The present study examined the persistence of early emerging aberrant behaviors in 13 preschool-aged children with severe disabilities. Aberrant behaviors were assessed every 6 months over a 3-year period. Given the longitudinal nature of the study, the resulting data may provide some evidence related to the persistence of early emerging aberrant behaviors during the preschool years, which may in turn assist prevention efforts.
2. Method 2.1. Participants and settings Thirteen preschool children (10 boys, 3 girls) were assessed. Each had a diagnosis of developmental delay/disability with a variety of more specific diagnoses represented in the group. When the study began, the children had a mean age of 47 months (range = 35–55 months). Table 1 lists the gender, age (in months at the start of the study), and diagnosis for each child. Criteria for selection in this study included: (a) a diagnosis of developmental delay/disability, autism, or other developmental disorder of a severe nature; (b) aged between 24 and 60 months; and (c) severe communication impairment evidenced by a language age of less than 24 months (mean = 9.23 months; range = 3.5–21 months) based Table 1 Gender, age (in months), and diagnosis of each child at the start of the study Child
Gender
Age (in months)
Diagnosis
AL LT DK MF MJ MT EM DP OR CE SC TG NB
M M M M M M F F M F M M M
39 51 42 43 51 44 35 55 54 51 55 49 40
Autism Autism Autism Down syndrome, epilepsy Developmental delay (unknown etiology) Periventricular leukomalacia Lennox–Gastaut syndrome Developmental delay (unknown etiology) Partial agenisis of corpus collosum C.H.A.R.G.E. Syndrome Developmental delay (unknown etiology) Autism Chromosome 5 abnormality
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on the Receptive-Expressive Emergent Language Scale (Bzoch & League, 1991). Given these characteristics, the children were considered to be at-risk for severe behavior problems (Schroeder et al., 1997). The 13 children lived at home with their parents and were recruited from preschools, where they received early intervention services. Their preschool programs were located in several comparable suburbs in a metropolitan area with a population of approximately 1 million. Children were mainly from Caucasian, English-speaking, and middle-class families. The children were educated in classrooms that usually included four to six other students. Each classroom had a full-time certified special education teacher and one or more teaching assistants. Teachers had known each child for at least 6 months prior to completing the assessments. These preschool programs included provision of special education as well as occupational, physical, and speech therapy. The programs used developmentally appropriate practices and followed a functional curriculum involving activity-based instruction to teach self-care, motor, communication, social, and preacademic skills (e.g., matching, imitation). 2.2. Procedure For the six rounds of data collection, teachers rated the severity of each child’s aberrant behavior using the Aberrant Behavior Checklist (ABC) (Aman & Singh, 1986, 1994). For the first two rounds, assessments were made using the original version of the ABC (Aman & Singh, 1986). For all subsequent rounds the newer Community version of the ABC was used (Aman & Singh, 1994). The Community version only became available after the first year of the project. The two versions are essentially identical except that the Community version includes wording more appropriate for preschool children and community settings. For example, Item 1 in the original version is ‘‘Excessively active on ward’’ whereas on the Community version it is ‘‘Excessively active at home, school, work or elsewhere.’’ The ABC is an empirically-derived rating scale containing 58 statements of problem behaviors that have been observed in persons with developmental disabilities (e.g., Item 2: Injures self on purpose; Item 47: Stamps feet or bangs objects or slams doors). Each item is rated on a four-point scale: 0 (not at all a problem), 1 (the behavior is a problem but slight in degree), 2 (the problem is moderately serious), 3 (the problem is severe in degree). This device was selected for use in the present study because it is reliable for assessing aberrant behavior in young children with developmental disabilities, appears sensitive to small changes in frequency and severity of problem behaviors, and is relatively quick and easy for teachers to complete (Sigafoos, Pittendreigh, & Pennell, 1997). Scores on the ABC can range from 0 to 174 with higher scores indicating more severe behavior disorder.
3. Results and discussion Table 2 shows total ABC scores for each child and for each round of data collection. Three patterns are evident. The first and most common pattern is found in 9 of the 13 children (AL, LT, DK, MF, MJ, MT, EM, DP, and OR). At Round 1, these 9 children obtained relatively high total scores on the ABC (range = 32–95, mean = 63). Three years
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Table 2 Total ABC scores for each child across the six rounds of data collection Round
AL
LT
DK
MF
MJ
MT
EM
DP
OR
CE
SC
TG
NB
1 2 3 4 5 6
95 90 84 71 86 90
81 97 89 03 61 63
61 57 67 47 66 73
53 57 82 68 83 60
72 116 115 84 80 52
74 63 62 67 57 60
46 63 77 36 27 32
56 69 45 32 62 50
32 30 50 11 65 33
36 36 13 08 07 02
16 15 09 09 03 02
18 00 01 03 0 0
22 05 27 21 74 78
later (Round 6), this sub-group of 9 children still had relatively high total scores (range = 32–90; mean = 57). Overall, there was little change in ABC scores for these 9 children from round to round, with the exception of inexplicably lower scores for LT and OR at Round 4. The second pattern, evident in 3 children (CE, SC, and TG), is characterized by relatively lower initial scores at Round 1 (mean = 23). This was followed by a steady reduction in scores over time so that by Round 6, these 3 children had negligible ratings on the ABC (mean <2). A third pattern was found for one child (NB). His ABC scores increased considerably from Round 1 (22) to Round 6 (78). Although there do not appear to be specific norms for preschool children with developmental disabilities, the ABC scores reported for the initial round of data collection would seem to reflect considerable levels of aberrant behavior (Aman & Singh, 1986; Brown, Aman, & Havercamp, 2002). Brown et al., for example, developed norms for children with developmental and physical disabilities that reflect generally lower scores, but their ratings came from parents of older children (6–18 years). Because we followed children only through the preschool years, it is unclear if our sample would show a trend towards the lower ABC scores reported by Brown et al. as they progressed through primary school. What is clear is that at the beginning of the present study, all of the children presented with multiple aberrant behaviors many of which were rated as moderately serious and at least some of which were considered severe in degree. Consider that to obtain even the lowest Round 1 score of 16 (Child SC), for example, indicates the presence of numerous aberrant behaviors that were considered by the teacher to be moderately serious or severe in degree. Overall the data in Table 2 can be interpreted as revealing that a number of moderate/ severe aberrant behaviors were identified in each child from an early age. Anecdotally, parents reported that aberrant behaviors emerged well before this study began, with many children showing symptoms beginning around 18–24 months of age. Table 2 further shows that in 9 of the 13 children, high ratings of aberrant behaviors persisted throughout the preschool years. The high prevalence and persistence of numerous aberrant behaviors is consistently found in studies of older individuals with developmental disabilities (Einfeld & Tonge, 1996; Einfeld et al., 1999, 2001; Emerson et al., 2001a, 2001b; Jones, 1999; Tonge & Einfeld, 1991). Our findings extend the existing literature in showing that numerous aberrant behaviors were also highly prevalent and persistent in preschool children with developmental disabilities. This new evidence suggests that aberrant behaviors can emerge
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early and are unlikely to improve with the mere passage of time. More specifically, our data suggest that children with developmental disabilities who show moderate to severe aberrant behaviors at 4 years of age are unlikely to outgrow these behaviors during the preschool years. This implies the need for explicit intervention to prevent and reduce aberrant behaviors in preschool children with developmental disabilities. Given the fact that all of the children had at least some moderately serious aberrant behaviors at the start of the study, prevention efforts could target these behaviors before they become more serious as well as instituting treatment for any existing serious problem behaviors. Given that all of the children lived at home and averaged less than 4 years of age when the study began, effective prevention and treatment would, therefore, seem to require home-based interventions that begin much earlier than 4 years of age. In addition, although all of the children attended preschool programs for the entire 3 years of the study, the persistence of moderately serious and severe aberrant behaviors in the majority of children suggests that these programs were generally ineffective when it came to the prevention and treatment of aberrant behavior. This is surprising given that these preschool programs implemented a functional curriculum in the context of developmentally appropriate activities, which is considered current best practice (Sigafoos et al., 2003). In addition, the programs were staffed by qualified special education professionals, had low teacher to student ratios (1:3–4), and included input from educational teams that included speech, physical, and occupational therapists. The seeming failure of these programs to reduce aberrant behaviors is distressing in that it could signal the need for additional and more specialized expertise than is currently provided even in well-funded, state-of-the-art preschools. Current evidence shows that the most effective interventions for the treatment of aberrant behaviors in individuals with developmental disabilities begin with functional assessments followed by functionally-derived interventions to replace aberrant behaviors with socially acceptable and functionally equivalent alternatives (Didden, Duker, & Korzilius, 1997). In many cases, the logical replacement behavior will represent a more socially acceptable form of communication based on the hypothesis that aberrant behaviors often serve a communicative function (Carr et al., 1994; Durand, 1993). The fact that all of the children in the present study had significant limitations in speech and language would not only seem to support the hypothesis that severe communication impairment is a risk factor for aberrant behavior (Schroeder et al., 1997; Sigafoos, 2000), but also that much aberrant behavior may have a communicative basis. The communication hypothesis conceptualizes aberrant behaviors as communicative acts that serve one or more of the following operant functions: (a) recruiting attention, (b) gaining and maintaining access to preferred objects or activities, and (c) rejecting nonpreferred objects or activities (Carr et al., 1994; Durand, 1993). Sigafoos, O’Reilly, Drasgow, and Reichle (2002) delineated a mechanism that might explain the early emergence, high prevalence, and long-term persistence of aberrant behavior. Prior to the emergence of speech, and when speech is absent or significantly delayed, children often rely on prelinguistic acts to communicate. Prelinguistic acts include facial expressions, body movements, undifferentiated vocalizations, reaching, and guiding for example. These behaviors can be subtle and highly idiosyncratic, which often makes it difficult for parents and preschool teachers to interpret the child’s communicative signals.
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As a result, there may be frequent communicative breakdowns. To repair these breakdowns, the child may intensify their initial prelinguistic behavior, so that the vocalization now becomes a scream, the reach becomes an aggressive grab, and initially uncoordinated arm movements might even become self-injurious face slapping. If parents and teachers respond to the intensification of forms, then this could explain how aberrant behaviors are shaped from existing prelinguistic behaviors. In the absence of effective intervention to teach alternative and more readily interpreted forms of communication (e.g., manual signs, picture-based communication systems) it is perhaps understandable that aberrant behaviors would persist, especially if these acts represent the child’s only or most effective means of expressing their wants and needs. This interpretation is consistent with several converging lines of evidence. Brady and Halle (2002), for example, reviewed evidence from communication theory indicating that children with developmental disabilities frequently attempt to repair communicative breakdowns by escalating to more intense forms of prelinguistic behavior. In addition, emerging developmental data suggest that there are early precursors to aberrant behaviors, which consist of less intense forms (Berkson, 2002; Berkson et al., 2001; Hall, Oliver, & Murphy, 2001). If this is the case, then early intervention and prevention might be improved by directing treatment strategies towards the early precursors of aberrant behaviors, rather than waiting until the problem becomes more serious or hoping that presenting problems will resolve as the child ages. The results of the present study should be interpreted with caution for several reasons. First, the sample consisted of only 13 children who were considered to be at-risk for developing aberrant behaviors. It is, therefore, unclear if these results would hold for other children with different characteristics. Second, only teachers completed the ratings of aberrant behavior. This was considered appropriate given that the teachers were using a reliable instrument, had known the children for at least 6 months, and had taught the children in a variety of preschool activities. Future research could be improved by obtaining ratings of aberrant behavior in multiple settings (e.g., home, community, and preschool) using multiple informants (e.g., parents, teachers, siblings, peers). This approach could provide data on interpersonal and environmental factors that influence aberrant behaviors, which in turn would have implications for designing intervention. Third, the data are descriptive, and therefore, do not isolate factors that might have influenced the early emergence and persistence of aberrant behaviors. Studies involving larger samples with systematic controls of child and family characteristics, and environmental influences (e.g., syndrome, adaptive behavior, family SES, interventions used) are needed as such data may help identify factors that could be addressed to reduce the risk of a child developing aberrant behaviors. Despite these limitations, our descriptive data provide useful information on the persistence of early emerging aberrant behaviors in a sample of 13 young children with developmental disabilities. The results showed that aberrant behaviors were highly prevalent and persistent in this sample of 13 preschool children with developmental disabilities. Several tentative implications can be developed from these findings. First, early intervention would seem to be needed to prevent and reduce aberrant behavior. Second, effective prevention would seem to require that the intervention effort begin well before the child reaches 4 years of age. And, third, prevention might be enhanced by
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directing intervention strategies towards the replacement of early and less serious forms of aberrant behavior as well as the prelinguistic acts that could be the precursors to aberrant behavior. Early intervention might include strategies to replace the child’s prelinguistic acts with more symbolic forms of communication. This approach would seem to require training professionals to collaborate with parents to identify early aberrant behaviors and then implement strategies to replace early aberrant behaviors with socially acceptable alternatives. Effective strategies to replace prelinguistic behaviors with alternative and more symbolic forms of communication have been developed and shown to be effective when used with young children with developmental disabilities (Keen, Sigafoos, & Woodyatt, 2001). The utility of these strategies when they are directed at replacing early aberrant behaviors would seem to be an obvious area for future research.
References Aman, M. G., & Singh, N. N. (1986). Aberrant Behavior Checklist: Manual. East Aurora, NY: Slosson Educational Publications. Aman, M. G., & Singh, N. N. (1994). Aberrant Behavior Checklist—Community. East Aurora, NY: Slosson Educational Publications. Berkson, G. (2002). Early development of stereotyped and self-injurious behaviors: II. Age trends. American Journal on Mental Retardation, 107, 468–477. Berkson, G., Tupa, M., & Sherman, L. (2001). Early development of stereotyped and self-injurious behaviors: I. Incidence. American Journal on Mental Retardation, 106, 539–547. Brady, N. C., & Halle, J. W. (2002). Breakdowns and repairs in conversations between beginning AAC users and their partners. In J. Reichle, D. R. Beukelman & J. C. Light (Eds.), Exemplary practices for beginning communicators: Implications for AAC (pp. 323–351). Baltimore: Paul H. Brookes Publishing Co. Brown, E. C., Aman, M. G., & Havercamp, S. M. (2002). Factor analysis and norms for parent ratings on the Aberrant Behavior Checklist-Community for young people in special education. Research in Developmental Disabilities, 23, 45–60. Bzoch, K. R., & League, R. (1991). Receptive-Expressive Emergent Language Scale. (2nd ed.). Austin, TX: Proed. Carr, E. G., Levin, L., McConnachie, G., Carlson, J. I., Kemp, D. C., & Smith, C. E. (1994). Communication-based intervention for problem behavior. Baltimore: Paul H. Brookes Publishing Co. Didden, R., Duker, P. C., & Korzilius, H. (1997). Meta-analytic study on treatment effectiveness for problem behavior with individuals who have mental retardation. American Journal on Mental Retardation, 101, 387– 399. Dunlap, G., Robbins, F. R., & Darrow, M. A. (1994). Parents’ reports of their children’s challenging behavior: Results of a statewide survey. Mental Retardation, 32, 206–212. Durand, V.M. (1993). Problem behavior as communication. Behaviour Change, 10, 126–197. Einfeld, S. E., & Tonge, B. J. (1996). Population prevalence of psychopathology in children and adolescents with mental retardation: II Epidemiological findings. Journal of Intellectual Disability Research, 40, 99–109. Einfeld, S. E., Tonge, B. J., & Rees, V. W. (2001). Longitudinal course of behavioral and emotional problems in Williams syndrome. American Journal on Mental Retardation, 106, 73–81. Einfeld, S. E., Tonge, B. J., Turner, G., Parmenter, T., & Smith, A. (1999). Longitudinal course of behavioural and emotional problems in young persons with Prader-Willi, Fragile X, Williams, and Down syndromes. Journal of Intellectual and Developmental Disability, 24, 349–354. Emerson, E., Kiernan, C., Alborz, A., Reeves, D., Mason, H., Swarbrick, R. et al. (2001). The prevalence of challenging behaviors: a total population study. Research in Developmental Disabilities, 22, 77–93. 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.
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Hall, S., Oliver, C., & Murphy, G. (2001). Early development of self-injurious behavior: An empirical study. American Journal on Mental Retardation, 106, 189–199. Hastings, R. P., & Brown, T. (2000). Functional assessment and challenging behaviors: Some future directions. Journal of the Association for Persons with Severe Handicaps, 25, 229–240. Jones, R.S.P. (1999). A 10 year follow-up of stereotypic behavior with eight participants. Behavioral Intervention, 14, 45–54. Keen, D., Sigafoos, J., & Woodyatt, G. (2001). Replacing prelinguistic behaviors with functional communication. Journal of Autism and Developmental Disorders, 31, 385–398. Murphy, G., Hall, S., Oliver, C., & Kissi-Debra, R. (1999). Identification of early self-injurious behavior in young children with intellectual disability. Journal of Intellectual Disability Research, 43, 149–163. Schroeder, S. R., Tessel, R. E., Loupe, P. S., & Stodgell, C. J. (1997). Severe behavior problems among people with developmental disabilities. In W. E. MacLean, Jr. (Ed.), Ellis’ handbook of mental deficiency, psychological theory, and research (3rd ed., pp. 439–464). Hillsdale, NJ: Lawrence Erlbaum. Sigafoos, J. (2000). Communication development and aberrant behavior in children with developmental disabilities. Education and Training in Mental Retardation and Developmental Disabilities, 35, 168–176. Sigafoos, J., Arthur, M., & O’Reilly, M. (2003). Challenging behavior and developmental disability. London: Whurr. Sigafoos, J., O’Reilly, M., Drasgow, E., & Reichle, J. (2002). Strategies to achieve socially acceptable escape and avoidance. In J. Reichle, D. Buekelman & J. Light (Eds.), Exemplary practices for beginning communicators (pp. 157–186). Baltimore: Paul H. Brookes Publishing Co. Sigafoos, J., Pittendreigh, N., & Pennell, D. (1997). Parent and teacher ratings of challenging behaviour in young children with developmental disabilities. British Journal of Learning Disabilities, 25, 13–17. Tonge, B. J., & Einfeld, S. L. (1991). Intellectual disability and psychopathology in Australian children. Australia & New Zealand Journal of Developmental Disabilities, 17, 155–167.
Persistence of early emerging aberrant behavior in children with developmental disabilities Vanessa A. Greena,*, Mark O’Reillyb, Jonathan Itchona, Jeff Sigafoosb a
Department of Educational Psychology, The University of Texas at Austin, 1 University Station, D5800, Austin, TX 78712-1290, USA b Department of Special Education, The University of Texas at Austin, 1 University Station, D5800, Austin, TX 78712-1290, USA Received 25 March 2004; received in revised form 28 June 2004; accepted 8 July 2004
Abstract This study examined the persistence of early emerging aberrant behavior in 13 preschool children with developmental disabilities. The severity of aberrant behavior was assessed every 6 months over a 3-year period. Teachers completed the assessments using the Aberrant Behavior Checklist [Aman, M. G., & Singh, N. N. (1986). Aberrant Behavior Checklist: Manual. East Aurora, NY: Slosson Educational Publications; (1994). Aberrant Behavior Checklist—Community. East Aurora, NY: Slosson Educational Publications]. Problem behaviors were present in all children at the beginning of the study. Nine of the 13 children entered the study with relatively high levels of aberrant behaviors that showed little change over the 3 years. These data suggest that aberrant behaviors often emerge early and can be highly persistent during the preschool years. Prevention would, therefore, seem to require home-based interventions that begin before 4 years of age. # 2004 Elsevier Ltd. All rights reserved. Keywords: Aberrant behavior; Developmental disabilities; Early intervention
* Corresponding author. E-mail address: [email protected] (V.A. Green). 0891-4222/$ – see front matter # 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.ridd.2004.07.003
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1. Introduction Aberrant behaviors, such as aggression, self-injury, property destruction, stereotyped movements, and extreme tantrums are highly prevalent in individuals with developmental disabilities (Emerson et al., 2001a). Given this high prevalence, it is not surprising that the treatment of aberrant behaviors is a major priority in developmental disability services. Advances in functional assessment methodology have lead to a range of new and improved interventions for the treatment of aberrant behaviors in individuals with developmental disabilities (Hastings & Brown, 2000). Relatively less research has focused on the prevention of aberrant behavior in young children with developmental disabilities (Sigafoos, Arthur, & O’Reilly, 2003). It is possible that a better understanding of the early development and longitudinal course of aberrant behaviors in young children with developmental disabilities may lead to improved prevention efforts. Along these lines, several studies have investigated the persistence of aberrant behaviors in individuals with developmental disabilities. Emerson et al. (2001b), for example, found that self-injurious behaviors were highly persistent over a 7-year period in a sample of 95 individuals receiving mental retardation services in the United Kingdom. Jones (1999) found that the stereotyped movements initially observed in eight adults with developmental disabilities were still evident 10 years later. In a more comprehensive study, Einfeld and his colleagues (Einfeld & Tonge, 1996; Einfeld, Tonge, & Rees, 2001; Einfeld, Tonge, Turner, Parmenter, & Smith, 1999; Tonge & Einfeld, 1991) tracked a sample of Australian children and adolescents with intellectual disabilities for 5 years to ascertain the prevalence of behavioral and emotional problems. They found that behavioral and emotional problems were highly prevalent (30%) and highly persistent in this sample, especially for individuals with certain types of disability syndromes. For example, behavioral and emotional problems were more common in individuals with Prader-Willi and Williams syndrome, when compared to individuals with Down syndrome (Einfeld et al., 1999). However, these previous studies have tended to focus on specific forms of aberrant behaviors (e.g., self-injury, stereotyped movements) and/or on older individuals. For example, the average age of the various syndrome groups in the Einfeld et al. (1999) study ranged from 9.5 to 17.2 years. It is therefore difficult to know if similar trends would be found in younger children. Longitudinal studies of younger children would, seem necessary to extend the current knowledge base. In addition to extending the current knowledge base to younger children, longitudinal assessments of aberrant behavior in young children with developmental disabilities may provide much needed data on the persistence of early emerging aberrant behaviors. Berkson and colleagues (Berkson, 2002; Berkson, Tupa, & Sherman, 2001) studied infants and toddlers with severe disabilities for signs of emerging stereotyped and selfinjurious behaviors. Their results suggest that these forms of aberrant behavior may emerge with the toddlers’ advancing motor skills and persist beyond 3 years of age. Murphy, Hall, Oliver, and Kissi-Debra (1999) noted, that ‘‘Very little is known about the early stages of self-injurious behavior (SIB) in young children with developmental disabilities . . .’’ (p. 149). They did, however, show that teachers might be able to identify early forms of self-injury in school-aged children with severe mental retardation and/or autism.
V.A. Green et al. / Research in Developmental Disabilities 26 (2005) 47–55
49
Equally little is known about the early emergence and persistence of a range of other aberrant behaviors that are prevalent in children with developmental disabilities (Dunlap, Robbins, & Darrow, 1994). The lack of knowledge is addressed in the present study through a longitudinal study of preschool children who were considered to be at-risk for aberrant behaviors because of the severe nature of their disability (Schroeder, Tessel, Loupe, & Stodgell, 1997). If early and less serious aberrant behaviors can be identified in at-risk preschool children, then treatment can begin before these aberrant behaviors become more severe and firmly established. This in turn may improve treatment outcomes and may even help to prevent early and mild forms of aberrant behaviors from developing into more entrenched and serious challenging behaviors. The present study examined the persistence of early emerging aberrant behaviors in 13 preschool-aged children with severe disabilities. Aberrant behaviors were assessed every 6 months over a 3-year period. Given the longitudinal nature of the study, the resulting data may provide some evidence related to the persistence of early emerging aberrant behaviors during the preschool years, which may in turn assist prevention efforts.
2. Method 2.1. Participants and settings Thirteen preschool children (10 boys, 3 girls) were assessed. Each had a diagnosis of developmental delay/disability with a variety of more specific diagnoses represented in the group. When the study began, the children had a mean age of 47 months (range = 35–55 months). Table 1 lists the gender, age (in months at the start of the study), and diagnosis for each child. Criteria for selection in this study included: (a) a diagnosis of developmental delay/disability, autism, or other developmental disorder of a severe nature; (b) aged between 24 and 60 months; and (c) severe communication impairment evidenced by a language age of less than 24 months (mean = 9.23 months; range = 3.5–21 months) based Table 1 Gender, age (in months), and diagnosis of each child at the start of the study Child
Gender
Age (in months)
Diagnosis
AL LT DK MF MJ MT EM DP OR CE SC TG NB
M M M M M M F F M F M M M
39 51 42 43 51 44 35 55 54 51 55 49 40
Autism Autism Autism Down syndrome, epilepsy Developmental delay (unknown etiology) Periventricular leukomalacia Lennox–Gastaut syndrome Developmental delay (unknown etiology) Partial agenisis of corpus collosum C.H.A.R.G.E. Syndrome Developmental delay (unknown etiology) Autism Chromosome 5 abnormality
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on the Receptive-Expressive Emergent Language Scale (Bzoch & League, 1991). Given these characteristics, the children were considered to be at-risk for severe behavior problems (Schroeder et al., 1997). The 13 children lived at home with their parents and were recruited from preschools, where they received early intervention services. Their preschool programs were located in several comparable suburbs in a metropolitan area with a population of approximately 1 million. Children were mainly from Caucasian, English-speaking, and middle-class families. The children were educated in classrooms that usually included four to six other students. Each classroom had a full-time certified special education teacher and one or more teaching assistants. Teachers had known each child for at least 6 months prior to completing the assessments. These preschool programs included provision of special education as well as occupational, physical, and speech therapy. The programs used developmentally appropriate practices and followed a functional curriculum involving activity-based instruction to teach self-care, motor, communication, social, and preacademic skills (e.g., matching, imitation). 2.2. Procedure For the six rounds of data collection, teachers rated the severity of each child’s aberrant behavior using the Aberrant Behavior Checklist (ABC) (Aman & Singh, 1986, 1994). For the first two rounds, assessments were made using the original version of the ABC (Aman & Singh, 1986). For all subsequent rounds the newer Community version of the ABC was used (Aman & Singh, 1994). The Community version only became available after the first year of the project. The two versions are essentially identical except that the Community version includes wording more appropriate for preschool children and community settings. For example, Item 1 in the original version is ‘‘Excessively active on ward’’ whereas on the Community version it is ‘‘Excessively active at home, school, work or elsewhere.’’ The ABC is an empirically-derived rating scale containing 58 statements of problem behaviors that have been observed in persons with developmental disabilities (e.g., Item 2: Injures self on purpose; Item 47: Stamps feet or bangs objects or slams doors). Each item is rated on a four-point scale: 0 (not at all a problem), 1 (the behavior is a problem but slight in degree), 2 (the problem is moderately serious), 3 (the problem is severe in degree). This device was selected for use in the present study because it is reliable for assessing aberrant behavior in young children with developmental disabilities, appears sensitive to small changes in frequency and severity of problem behaviors, and is relatively quick and easy for teachers to complete (Sigafoos, Pittendreigh, & Pennell, 1997). Scores on the ABC can range from 0 to 174 with higher scores indicating more severe behavior disorder.
3. Results and discussion Table 2 shows total ABC scores for each child and for each round of data collection. Three patterns are evident. The first and most common pattern is found in 9 of the 13 children (AL, LT, DK, MF, MJ, MT, EM, DP, and OR). At Round 1, these 9 children obtained relatively high total scores on the ABC (range = 32–95, mean = 63). Three years
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Table 2 Total ABC scores for each child across the six rounds of data collection Round
AL
LT
DK
MF
MJ
MT
EM
DP
OR
CE
SC
TG
NB
1 2 3 4 5 6
95 90 84 71 86 90
81 97 89 03 61 63
61 57 67 47 66 73
53 57 82 68 83 60
72 116 115 84 80 52
74 63 62 67 57 60
46 63 77 36 27 32
56 69 45 32 62 50
32 30 50 11 65 33
36 36 13 08 07 02
16 15 09 09 03 02
18 00 01 03 0 0
22 05 27 21 74 78
later (Round 6), this sub-group of 9 children still had relatively high total scores (range = 32–90; mean = 57). Overall, there was little change in ABC scores for these 9 children from round to round, with the exception of inexplicably lower scores for LT and OR at Round 4. The second pattern, evident in 3 children (CE, SC, and TG), is characterized by relatively lower initial scores at Round 1 (mean = 23). This was followed by a steady reduction in scores over time so that by Round 6, these 3 children had negligible ratings on the ABC (mean <2). A third pattern was found for one child (NB). His ABC scores increased considerably from Round 1 (22) to Round 6 (78). Although there do not appear to be specific norms for preschool children with developmental disabilities, the ABC scores reported for the initial round of data collection would seem to reflect considerable levels of aberrant behavior (Aman & Singh, 1986; Brown, Aman, & Havercamp, 2002). Brown et al., for example, developed norms for children with developmental and physical disabilities that reflect generally lower scores, but their ratings came from parents of older children (6–18 years). Because we followed children only through the preschool years, it is unclear if our sample would show a trend towards the lower ABC scores reported by Brown et al. as they progressed through primary school. What is clear is that at the beginning of the present study, all of the children presented with multiple aberrant behaviors many of which were rated as moderately serious and at least some of which were considered severe in degree. Consider that to obtain even the lowest Round 1 score of 16 (Child SC), for example, indicates the presence of numerous aberrant behaviors that were considered by the teacher to be moderately serious or severe in degree. Overall the data in Table 2 can be interpreted as revealing that a number of moderate/ severe aberrant behaviors were identified in each child from an early age. Anecdotally, parents reported that aberrant behaviors emerged well before this study began, with many children showing symptoms beginning around 18–24 months of age. Table 2 further shows that in 9 of the 13 children, high ratings of aberrant behaviors persisted throughout the preschool years. The high prevalence and persistence of numerous aberrant behaviors is consistently found in studies of older individuals with developmental disabilities (Einfeld & Tonge, 1996; Einfeld et al., 1999, 2001; Emerson et al., 2001a, 2001b; Jones, 1999; Tonge & Einfeld, 1991). Our findings extend the existing literature in showing that numerous aberrant behaviors were also highly prevalent and persistent in preschool children with developmental disabilities. This new evidence suggests that aberrant behaviors can emerge
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early and are unlikely to improve with the mere passage of time. More specifically, our data suggest that children with developmental disabilities who show moderate to severe aberrant behaviors at 4 years of age are unlikely to outgrow these behaviors during the preschool years. This implies the need for explicit intervention to prevent and reduce aberrant behaviors in preschool children with developmental disabilities. Given the fact that all of the children had at least some moderately serious aberrant behaviors at the start of the study, prevention efforts could target these behaviors before they become more serious as well as instituting treatment for any existing serious problem behaviors. Given that all of the children lived at home and averaged less than 4 years of age when the study began, effective prevention and treatment would, therefore, seem to require home-based interventions that begin much earlier than 4 years of age. In addition, although all of the children attended preschool programs for the entire 3 years of the study, the persistence of moderately serious and severe aberrant behaviors in the majority of children suggests that these programs were generally ineffective when it came to the prevention and treatment of aberrant behavior. This is surprising given that these preschool programs implemented a functional curriculum in the context of developmentally appropriate activities, which is considered current best practice (Sigafoos et al., 2003). In addition, the programs were staffed by qualified special education professionals, had low teacher to student ratios (1:3–4), and included input from educational teams that included speech, physical, and occupational therapists. The seeming failure of these programs to reduce aberrant behaviors is distressing in that it could signal the need for additional and more specialized expertise than is currently provided even in well-funded, state-of-the-art preschools. Current evidence shows that the most effective interventions for the treatment of aberrant behaviors in individuals with developmental disabilities begin with functional assessments followed by functionally-derived interventions to replace aberrant behaviors with socially acceptable and functionally equivalent alternatives (Didden, Duker, & Korzilius, 1997). In many cases, the logical replacement behavior will represent a more socially acceptable form of communication based on the hypothesis that aberrant behaviors often serve a communicative function (Carr et al., 1994; Durand, 1993). The fact that all of the children in the present study had significant limitations in speech and language would not only seem to support the hypothesis that severe communication impairment is a risk factor for aberrant behavior (Schroeder et al., 1997; Sigafoos, 2000), but also that much aberrant behavior may have a communicative basis. The communication hypothesis conceptualizes aberrant behaviors as communicative acts that serve one or more of the following operant functions: (a) recruiting attention, (b) gaining and maintaining access to preferred objects or activities, and (c) rejecting nonpreferred objects or activities (Carr et al., 1994; Durand, 1993). Sigafoos, O’Reilly, Drasgow, and Reichle (2002) delineated a mechanism that might explain the early emergence, high prevalence, and long-term persistence of aberrant behavior. Prior to the emergence of speech, and when speech is absent or significantly delayed, children often rely on prelinguistic acts to communicate. Prelinguistic acts include facial expressions, body movements, undifferentiated vocalizations, reaching, and guiding for example. These behaviors can be subtle and highly idiosyncratic, which often makes it difficult for parents and preschool teachers to interpret the child’s communicative signals.
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As a result, there may be frequent communicative breakdowns. To repair these breakdowns, the child may intensify their initial prelinguistic behavior, so that the vocalization now becomes a scream, the reach becomes an aggressive grab, and initially uncoordinated arm movements might even become self-injurious face slapping. If parents and teachers respond to the intensification of forms, then this could explain how aberrant behaviors are shaped from existing prelinguistic behaviors. In the absence of effective intervention to teach alternative and more readily interpreted forms of communication (e.g., manual signs, picture-based communication systems) it is perhaps understandable that aberrant behaviors would persist, especially if these acts represent the child’s only or most effective means of expressing their wants and needs. This interpretation is consistent with several converging lines of evidence. Brady and Halle (2002), for example, reviewed evidence from communication theory indicating that children with developmental disabilities frequently attempt to repair communicative breakdowns by escalating to more intense forms of prelinguistic behavior. In addition, emerging developmental data suggest that there are early precursors to aberrant behaviors, which consist of less intense forms (Berkson, 2002; Berkson et al., 2001; Hall, Oliver, & Murphy, 2001). If this is the case, then early intervention and prevention might be improved by directing treatment strategies towards the early precursors of aberrant behaviors, rather than waiting until the problem becomes more serious or hoping that presenting problems will resolve as the child ages. The results of the present study should be interpreted with caution for several reasons. First, the sample consisted of only 13 children who were considered to be at-risk for developing aberrant behaviors. It is, therefore, unclear if these results would hold for other children with different characteristics. Second, only teachers completed the ratings of aberrant behavior. This was considered appropriate given that the teachers were using a reliable instrument, had known the children for at least 6 months, and had taught the children in a variety of preschool activities. Future research could be improved by obtaining ratings of aberrant behavior in multiple settings (e.g., home, community, and preschool) using multiple informants (e.g., parents, teachers, siblings, peers). This approach could provide data on interpersonal and environmental factors that influence aberrant behaviors, which in turn would have implications for designing intervention. Third, the data are descriptive, and therefore, do not isolate factors that might have influenced the early emergence and persistence of aberrant behaviors. Studies involving larger samples with systematic controls of child and family characteristics, and environmental influences (e.g., syndrome, adaptive behavior, family SES, interventions used) are needed as such data may help identify factors that could be addressed to reduce the risk of a child developing aberrant behaviors. Despite these limitations, our descriptive data provide useful information on the persistence of early emerging aberrant behaviors in a sample of 13 young children with developmental disabilities. The results showed that aberrant behaviors were highly prevalent and persistent in this sample of 13 preschool children with developmental disabilities. Several tentative implications can be developed from these findings. First, early intervention would seem to be needed to prevent and reduce aberrant behavior. Second, effective prevention would seem to require that the intervention effort begin well before the child reaches 4 years of age. And, third, prevention might be enhanced by
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directing intervention strategies towards the replacement of early and less serious forms of aberrant behavior as well as the prelinguistic acts that could be the precursors to aberrant behavior. Early intervention might include strategies to replace the child’s prelinguistic acts with more symbolic forms of communication. This approach would seem to require training professionals to collaborate with parents to identify early aberrant behaviors and then implement strategies to replace early aberrant behaviors with socially acceptable alternatives. Effective strategies to replace prelinguistic behaviors with alternative and more symbolic forms of communication have been developed and shown to be effective when used with young children with developmental disabilities (Keen, Sigafoos, & Woodyatt, 2001). The utility of these strategies when they are directed at replacing early aberrant behaviors would seem to be an obvious area for future research.
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