- Email: [email protected]
Problem behavior and psychiatric impairment within a developmentally disabled population I: Behavior frequency
Applied Research in Mental Retardation, Vol. 3, pp. 121 - | 39, 1982 Printed in the USA. All rights reserved.
0270 - 3092/82/020121- 19503.00/0 Copyright © 1982 Pergamon Press Ltd
Problem Behavior and Psychiatric Impairment Within a Developmentally Disabled Population I: Behavior Frequency John W. lacobson New York State Office of Mental Retardation and Developmental Disabilities
This report summarizes information about problem behavior and psychiatric impairment in a population of over 30,000 individuals receiving developmental disabilities services. Teenage and adult individuals displayed more problem behaviors than young children or the elderly, more markedly mentally retarded individuals were more likely to display problem behavior, individuals in less restrictive residential settings displayed less problem behavior than those in more restrictive settings, and persons with psychiatric impairment displayed more frequent problems than persons without psychiatric impairment. The proportion of developmentally disabled persons with a psychiatric impairment was positively associated with presence of problem behaviors classified as affective or cognitive. Implications for community placement and further research are addressed.
During the past decade the trend toward development of small residential settings and the adoption of institutional admission diversion policies has been accompanied by decreased use of large institutions for persons with developmental disabilities (DD). It has been projected that, during the next 10 years, the small (7 to 15 person) group home will constitute the primary living alternative for DD individuals placed out-of-home (Wolfensberger, 1969). However, much of the growth in community residential living alternatives has resulted from the return of relatively capable institutional residents to the community and it would Requests for reprints should be addressed to: John W. Jacobson, Bureau of Program Research and Planning, New York State Office of Mental Retardation and Developmental Disabilities, 44 Holland Avenue, Albany, New York 12229. 121
122
John W. Jacobson
appear that many future entrants to community residential programs will probably be more seriously or multiply disabled (Heal, Novak, Sigelman, & Switsky, 1980). If repatriation is to continue, the community service system will have to accommodate increasingly disabled individuals (both in regard to multiple handicaps and problem behavior) and continue to accommodate individuals who have never been institutionalized. An extensive literature has documented the difficulties that arise in community placement of multiply handicapped and behavior problem individuals (Bjaanes, Butler, & Kelly, 1980; Clark, 1959; Eagle, 1967; Nihira & Nihira, 1975; Taylor, 1976; Vogel, Kun, & Meshorer, 1969; Windle, Stewart, & Brown, 1961). These difficulties have helped to maintain interest in the practical management of problem behavior (see Mulick & Schroeder, 1980; Schroeder, Mulick, & Schroeder, 1979). Eyman and Call (1977), in a survey of 6,870 persons with mental retardation, found that, in general, more marked behavior problems are associated with greater degrees of retardation, and behavior problems are more frequently noted within institutions than in community settings. Although Eyman and Call reviewed only 11 behaviors the estimated prevalence of some of these is alarmingly high. For example, overall rates of 28% and 15% were obtained for the incidence of aggressive and self-injurious behaviors. These findings are in contrast with those of Landesman-Dwyer, Schuckit, Keller, and Brown (1977) who grouped 10,000 disabled persons into functional skills classes. They found no clear-cut relationship of problem behavior to functioning level, and as many as 50% of the members of any class displayed no problem behavior, or what the authors regarded as mild problem behavior. More recently, further discussion of the behaviors reviewed by Eyman and Call (1977) has been presented by Borthwick, Meyers, and Eyman (1981), and Hill and Bruininks (1981) have collected information about eight problem behaviors among 2,486 persons residing in public and private residential programs nationally as part of a more comprehensive investigation. Notably, 52.7% of community residential facility occupants and 40.3% of public residential facility occupants were reported as displaying none of these eight behaviors. A separate, but related issue concerns the extent of affective dysfunction among persons who also have a developmental disability. Prevalence estimates of psychiatric impairment range from 31% (Menalascino, 1965. 1966) to 100% (Webster, 1970) of cases, with intermediate proportions noted by others (Chess, 1970; Phillips & Williams, 1975; Szymanski, 1977). Generalizing from these reports is difficult because all are based upon data from children referred to clinics for psychiatric assessment. In contrast, Hill and Bruninks (1981) found that, among 1,486 DD residential program occupants, only 1.1% were reported to have behavior disorders. If the potential impact of problem behavior and psychiatric impairment upon community placement of developmentally disabled persons is to be understood, further attention to these factors is warranted. The present report summarizes
Behavior and Psychiatric Impairment
123
data regarding problem behavior, psychiatric impairment, level of intellectual functioning, and residential placement among developmentally disabled individuals in New York State. METHOD
Population The sample for this study consisted of 30,578 mentally retarded individuals residing either independently in the community, with their families, in family foster care, in community residences (group homes) or developmental centers (state-operated institutions), and for whom a current classification of intellectual functioning was available. Of this group 3,555 (11.6% overall; 9.8% of children and 12.4% of adults) had been classified as having a psychiatric disability. For purposes of analysis the behavior of persons with both psychiatric and developmental disabilities (termed PDD) and those with developmental disabilities solely (termed DD) was considered separately. Demographically, DD and PDD individuals were quite similar. Data on the age, gender, disability, and psychiatric impairment distributions of these groups are presented in Table 1.
TABLE 1 Percent Distribution of Population Characteristics
Developmentally Psychiatric/Developmentally Disabled Disabled (PDD) Age in Years 0-4 5-20 21-44 45-64 65 + Gender Male Female Disabilities Autism Cerebral palsy Epilepsy Mental retardation Other neurological impairments Psychiatric Impairments Psychosis Non-psychotic organic brain syndrome Personality disorder Other conditions Number of cases
4 25 48 18 5
1 25 51 19 4
55 45
60 40
1 13 22 100 14
5 5 26 100 17
0 0 0 0 27023
28 14 18 40 3555
124
John W. Jacobson
In reviewing tabular results, it will be noted that Table n's will vary. These n's reflect analyses of data at different points in a survey process (as the data base used continues to grow, information on more cases becomes available). Table n's which are either smaller or larger than those in Table 1 reflect groups which are equivalent in level of functioning and other characteristics to the Table 1 group. Instrument
Data on problem behavior and psychiatric impairment were extracted from the data base for the New York Developmental Disabilities Information Survey (DDIS) (Janicki & Jacobson, Note 1, Note 2). The DDIS is a comprehensive, population-based survey of individuals with developmental disabilities in New York State. Among the data elements within the DDIS is an item recording a maximum of three problem behaviors and general frequency for each behavior. Coding requires entry of values for the absence, as well as the presence, of such behavior. Of all problem behaviors reported, 69% occur weekly or daily and 18% occur monthly. Behaviors recorded are therefore a reflection of frequently occurring problems, rather than indications of past actions. Other items in the survey booklet collect information about level of intellectual functioning, current residential setting, and the presence of single and multiple diagnosed psychiatric impairment. Entry of this data is dependent upon the presence of substantiating material within the individual program plan. Protocols are completed by clinical staff with experience in the provision of DD services. Behaviors Addressed
The 29 behaviors selected for this report constitute the list of possible behaviors which may be indicated within the DDIS as obstacles to placement or provision of services (see section on presence of psychiatric impairment). For the purpose of analysis these behaviors have been grouped into four categories: cognitive, affective, major, and minor. Cognitive behaviors are those which have a likelihood of occurrence in instances of selective neurological deficit or psychosis. Affective behaviors are those which are associated with other psychiatric impairments and interpersonal immaturity. Major behaviors are violent, destructive, and antisocial acts which not only pose a serious barrier to community placement and maintenance but are also generally legally proscribed. (Minor behaviors include all those listed in Table 3 under the section presence of psychiatric impairment, which clinical experience and research suggest should occur in the target population.) The distinction between major and minor is intended to separate those behaviors which pose more versus less marked barriers to community placement. Differences in potential for amelioration should not be inferred between the two categories. Many "minor" behaviors, such as pica,
Behavior and Psychiatric Impairment
125
may be both hazardous to an individual's health and resistant to intervention. While the list of behaviors is brief, it appears of sufficient diversity; "other"/ unspecified problem behavior is reported for only 7.5% of all cases.
Procedure Group comparisons were performed using chi-squares and analyses of variance. With large sample sizes, such as those used in this report, it is possible to obtain statistically significant X 2 and F values which nonetheless represent minor differences between groups. For this reason, an additional parameter was computed for each analysis. For chi-squares the qualifying parameter was either ~b, the fourfold point correlation coefficient (2 x 2 or df = 1 contingency tables), or qb', Cramers's phi, a generalization of d~ to tables with other df (see Cohen, 1969). While not interpretable as a product-moment correlation, unlike a contingency coefficient it does have a range from 0 to 1 regardless of degrees of freedom, and may be used as an estimate of relationship. For each significent F value an omega-squared (~2) was computed. Omegasquared, in this application, reflects the proportion of variance among groups accounted for by each variable (see Keppel, 1973).
RESULTS
Population In Table 2 some variation in population distribution is apparent. As would be expected, residents of family care, community residences, and developmental centers evince lower levels of intellectual functioning than do persons living independently or with their families (X 2 = 9260, df = 12, p < .001, ~b' = .32). The proportion of persons with a psychiatric impairment varies as a function of setting (X 2 = 156, df = 4, p < .001, d~' = .07), level of intellectual functioning (X 2 = 336, df = 3, p < .001, ~b' = . 10), and age (X 2 = 40, df = l, p < .001, qb = .04). The proportion of persons with such impairment ranges from 22% of persons with normal intelligence to seven percent of persons with profound mental retardation. Thirteen percent of persons living with family, 14% in independent living, five percent in family care, 14% in community residences, and 12% in developmental centers evince psychiatric impairment. Finally, intellectual level distribution differed between DD and PDD groups living with family (X 2 = 19.5, df = 3, p < .001, ~ ' = .04), in family care (X 2 = 22.6. df = 3, p < .001, ~b' = .08), in community residences (X 2 = 47.5, df = 3, p < .001, ~b' = . 12), and in developmental centers (X: = 1549, df = 3, p < .001, qb' = .33). In general, DD groups evinced more marked
htekCNd
0 0 33 3
0 - 13 23
26 2
3
69
423
Number of cases (22 +)
4206
9 ----__
21
38
32
24 32 32 12 2424
41 32 17 10 565
149
7
31
28
34
4 25
32
20
35
19
20
44
PDD
655
12 33
32
DD
Family Care _
34
PDD
15 21 -------___ 540 3918
21
29
29
DD
Living with Family
*Percentages are percent of column totals within DDiPDD and setting
2
- 1
Profound mental retardation
Severe mental retardation
72
71 25
Moderate mental retardation
Years
Mild mental retardation
Persons 22+
Number of cases (O-21)
Profound mental retardation
Severe mental retardation
67
51
PDD
30
DD
Independent Living
Moderate mental retardation
Functioning
Mild mental retardation
Persons O-21 Years
Level of
2406
13
26
31
30
469
32
28
23
17
DD
413
7
18
30
44
69
21
19
32
28
PDD
Community Residence
2-l 35
24 60 96901504
15 23
41 218
73 2749
5
28
18
11
9 22
I
PDD
2
DD
Developmental Center
Level, and Setting*
Residential Setting
TABLE 2 Percent of Persons as a Function of Age, Intekctual
-- 35 19149
24
22
18
1814
39
22
21
18
DD
Overall
2700
24
23
26
27
855
22
21
30
21
PDD
Behavior and Psychiatric Impairment
127
degrees of mental retardation than the PDD groups in these settings; this was most apparent in community residences and developmental centers.
Presence of Psychiatric Impairment Comparisons were drawn between children and adults with and without psychiatric impairment (see Table 3). Among children problem behaviors were distributed differently and were more frequent in the PDD group (Fbehavior = 7.0, df = 28, 28, p < .001,~2 = .65;FDD/PDD = 34.7, df = 1,28, p < .001, t~2 = . 13). Among adults the PDD group also evinced more frequent and different problem behaviors (F~havio~ = 8.0, df = 28, 28, p < .001, ~2 = .69; FDD/PDD = 32.2, df = 1, 28, p < .001, ~2 = .11). Differences in distribution and overall frequency of behaviors was also apparent between DD children and adults (F~,avior = 22.3, d f = 28, 28, p < .001,~2 = .90;Fa~e = 7.3, d f = 1 , 2 8 , p < .001, t~2 = .01). Differences in the distribution of behaviors were also found between PDD children and adults (Fbehav~o~ ----- 12.3, df = 28, 28, p < A .001, co2 = .84), but discrepancies in the total number of behaviors displayed were non-significant. These findings are consistent with those of 3-way A N O V A wherein behavior frequency varied as a function of the behavior (~2 = .71) and DD/PDD group membership (t~2 = . 10), but not as a function of age. Interaction effects related to these variables were not noted. Comparisons of the PDD and DD groups without reference to age disclosed that behaviors in each category were more likely to occur among PDD individuals. This relationship was most marked for cognitive and affective behaviors (XZ¢og,,~vo = 362, ~b = .23; X2~ffe~,~ = 1517, ~b = .46; X2~jo~ = 69, ~b = .09; X2mi,o~ = 238, d~ = .18; all df = 1, a l l p < .001).
Age and Level of Intellectual Functioning Data in Table 4 (n = 32,427) are arrayed without reference to psychiatric impairment. Differences in proportions of behavior type were present across age groups within each level of functioning (X 2, all df = 9, all p < .001, with ~b' ranging from .07 for profound mental retardation to .01 for severe mental retardation). In general, persons age 0 - 2 1 displayed fewer cognitive and affective problems, and more minor problems than persons age 22 and older. Additionally, persons age 0 - 1 2 and 60 or older displayed fewer major behaviors than persons age 1 3 - 5 9 . Differences in proportions of age groups with problem behaviors were also present at each level of functioning (X 2, all df = 3, allp < .001, with d~' ranging from .24 for profound mental retardation to .08 for mild mental retardation). Persons age 0 - 1 2 were less likely to display problem behavior than older persons, particularly those age 2 2 - 5 9 .
128
John W. Jacobson TABLE 3 Percent of Cases for which each Behavior was Reported for Developmentally Disabled Persons, Psychiatric/Developmentally Disabled Persons, and Entire Data File Disability Group Developmentally Disabled
Psychiatric/ Developmentally Disabled
0-21 years
22+ years
0-21 years
22+ years
All
Cognitive problems Delusions/hallucinations Disorientation to time/place Perseveration Echolalia
0.4 1.7 2.1 1.3
1.4 4.0 2.9 1.3
4.7 6.1 5.8 4.6
10,3 9.0 5.4 2.1
2.2 3.8 2.8 1.3
Affective problems Extreme mood changes Appropriate affect not displayed Lack of interpersonal responsiveness Suicide threats/attempts Depression Extreme irritability
2.3 3.4 9.1 0.1 0.3 1.1
5.2 4.1 10.8 0.3 2.0 2.7
10.2 12.5 22.3 0.8 4.0 3.6
14.0 11.0 20.7 1.9 9.1 7.3
5.6 4.9 12.3 0.4 2.9 2.9
Major behaviors Physical assault upon others Property destruction Property theft Fire setting/attempts Coercive sexual behavior Inappropriate genital display Inappropriate public disrobing Self-injurious action
8.5 3.7 1.2 0.2 0.9 1.1 0.9 7.7
11.3 4.4 2.8 0.2 1.5 1.5 1.9 9.3
21.5 9.2 2.3 1.2 2.2 2.5 1.6 15.3
18.5 6.7 3.2 0.5 1.3 2.3 2.3 10.6
10.9 4.3 2,4 0.4 1.4 1.4 1.5 8.2
Minor behaviors Hyperactivity Stereotypic/repetitive movements Actively resists supervision Crying, temper tantrums Verbally abusive to others Wandering, roaming, running away Inappropriately handles bodily wastes Pica Blames others Substance abuse Other behavior (not specified)
9.3 7.0 7.0 13.8 2.4 5.7 1.5 1.9 0.7 0.1 6.8
5.4 5.6 7.7 13.2 6.3 4.5 1.8 1.9 2.2 0.2 7.2
21.0 8.7 13.5 20.7 6.8 9.8 1.6 3.0 0.9 0.2 8.1
10.1 6.9 12.9 16.7 12.2 7.0 1.9 2.1 3.4 0.7 7.9
7.4 5.8 8.1 13.7 5.9 4.9 1.6 1.9 1.7 0.4 7.5
Number of cases
7873
19149
855
2700
32112'
Overall*
*Includes 1535 additional persons residing in other settings
Level of lntellectual Functioning
Considerable variation was apparent in proportions of DD and PDD individuals reported as free of problem behavior based upon level of intellectual functioning. For example, among developmentally disabled individuals 54, 48, 40,
Behavior and Psychiatric Impairment
129
TABLE 4 Percentage of Behavior Problem Types as a Function of Age and Intellectual Level
Age within Level of Intellectual Functioning
n (Cases)
Percent without Problem Behaviors
Cognitive
Mild mentalretardation 0-12 13-21 22-59 60+
708 818 4024 641
60 45 50 57
11 5 8 18
14 26 35 32
14 19 14 11
61 50 43 39
Moderate mentalretard~ion 0-12 13-21 22-59 60+
640 1163 4866 632
53 40 45 56
8 7 10 13
19 22 27 32
14 24 20 13
59 47 44 58
Severe mentalretardmion 0-12 13-21 22-59 60+
652 1208 4754 841
46 35 36 42
5 6 8 12
15 14 20 29
17 30 26 19
63 50 44 40
Profound mentalretard~ion 0-12 13-21 22-59 60+
1056 2539 7175 710
62 43 25 33
4 4 7 12
19 15 17 26
22 33 33 22
55 48 43 40
Behavior Type* Affective Major
Minor
*Among individuals with a problem behavior reported only
and 35% o f groups with mild retardation, moderate retardation, severe retardation, and profound retardation, respectively, had no reported behaviors (X 2 = 576, df = 3, p < .001, ~b' = . 15). In comparison, the proportions without reported behavior in corresponding P D D groups were 14, 12, 9 and 12% (X 2 = 10.3, df = 3, p < .02, ~b' = .05). In s u m m a r y , 38.6% of D D and 9 . 8 % of P D D individuals had no reported p r o b l e m behaviors; P D D individuals were significantly more likely to display problem behavior (X 2 = 927, df = 1, p < .001, ~b = .29). These differences (X 2, df = 12, p < .001, . 12 ~< d~ ~< .29) were present at each level of intellectual functioning. Frequencies of specific behaviors differed significantly across levels of functioning for both children and adults (Fchildren = 15.6, t~2 = .78; Fadalts = 8.7, ~z = .62, both df = 28, 84, both p < .001), but the total n u m b e r of behaviors reported differed across intellectual levels for adults alone (F = 6.1, df = 3, 84, p < .01, ~2 = .04), although this accounted for only 4% of the total intergroup variance. Table 5 presents the percent of cases for which each b e h a v i o r was reported by level of intellectual functioning, without reference to psychiatric impairment.
1.4 1.4 2.4 1.5
3.8 4.2 8.9 0.4 2.0 1.4
5.5 2.1 1.9 0.7 1.5 O. 1 0.1 1.8
Cognitive problems Delusions/hallucinations Disorientation to time/place Perseveration Echolalia
Affective problems Extreme mood changes Appropriate affect not displayed Lack of interpersonal responsivaness Suicide threats/attempts Depression Extreme irritability
Major behaviors Physical assault upon others Property destruction Property theft Fire setting/attempts Coercive sexual behavior Inappropriate genital display Inappropriate public disrobing Self-injurious behavior 5.5 1.8 2.5 0.4 1.7 0.6 0.3 2.9
7.2 5,5 10.6 1.4 6.2 4.1
3.4 1.9 2.0 0.5
8.0 4.0 2.2 0.6 1.4 1.1 0.2 3.4
3.9 5.8 9.7 0.2 1.2 1.7
0.9 2.3 3.6 2.4
8.5 3.3 2.5 0.3 1.5 0.7 0.4 3.4
7.3 4.8 10.0 0.6 3.6 4.0
3.3 2.4 3.4 0.9
22+ years
0-21 years
0-21 years
22+ years
Moderate Mental Retardation
Mild Mental Retardation
12.5 5.7 0.9 0.2 1.1 1.5 1.5 9.1
4.6 4.1 10.5 0.1 0.2 1.7
0.8 2.0 3.4 2,6
0-21 years
13.9 5.3 3.4 0.2 1.6 1.1 1.3 6.4
7.2 4.5 12.4 0.2 2.4 2.7
2.8 4.4 3.8 2.5
22+ years
Severe Mental Retardation
TABLE 5 Percent of Cases for which each Behavior was Reported by Intellectual Level and Age
11.2 4.6 0.8 O. 1 0.5 1.8 1.5 14.3
3.2 3.6 11.6 0.0 0.2 1.2
0.4 2.3 1.2 0.8
O- 21 years
17.3 6,8 2.9 O. 1 1.7 3.2 4.5 18.0
4.7 5.0 16.8 0.1 0.9 2.3
1.3 7.6 3.2 1.9
22 + years
Profound Mental Retardatiofi
7.0 1.9 9.6 11.5 6.0 5.2 0.4 0.7 1.5 0.4 13.2
1627
Minor behaviors Hyperactivity Stereotypic/repetitive movements Actively resists supervision Crying, temper tantrums Verbally abusive to others Wandering, roaming, running away Inappropriately handles bodily wastes Pica Blames others Substance abuse Other behavior (not specified)
Number of cases
4163
2.3 1.6 7.7 8.0 9.5 2.9 0.2 0.2 4.2 0.8 7.6 1930
8.8 4.6 7.5 13.6 5.2 6.1 0.3 0.6 1.3 0.1 7.9 5010
3.7 2.6 8.1 11.3 9.8 3.5 0.4 0.2 3.3 0.2 6.7 1876
13.5 8.7 9.0 17.6 1.8 7.7 1.4 2.4 0.4 0.1 6.4 5249
5.5 4.3 8.5 16.1 8.4 4.7 0.9 0.8 2.5 0.1 7.0 3295
9.5 10.4 6.0 14.7 0.4 5.7 2.8 3.4 0.2 0.0 6.3 7427
11.3 8.7 16.7 2.7 6.9 4.2 4.8 0.5 0.2 7.8
11.2
~r'
"u
g-
* * * * * * * * * * * * * * * * * *
Cognitive problems Delusions/Hallucinations Disorientation to time/place Perseverafion Echolalia
Affective problems Extreme mood changes Appropriate affect not displayed Lack of interpersonal responsiveness Suicide threats/attempts Depression ExUeme irritability
Major behaviors Physical assault upon others Property destruction Property theft F'tre setting/attempts Coercive sexual behavior Inappropriate genital display Inappropriate public disrobing Self-injurious action
0-21 years
2.3 1.4 1.8 0.5 0.6 0.1 0.0 1.2
7.8 3.9 8.2 3.0 10.4 3.9
2.9 1.0 0.6 0.0
22+ years
Independent Living
4.9 2.4 0.7 0.3 0.4 0.6 0.4 4.2
3.2 5.4 10.0 0.2 0.9 1.5
0.1 2.4 3.4 2.0
0-21 years
3.6 1.1 0.9 0.1 0.7 0.5 0.2 1.7
4.5 5.1 11.5 0.3 3.1 2.7
2.4 2.0 3.3 1.2
22+ years
Living with Parents
2.9 2.2 1.5 0.3 0.7 0.4 0.3 2.4
1.8 2.1 6.2 0.0 0.3 0.3
0.4 1.3 1.5 2.2
0-21 years
2.8 2.2 2.4 0.2 0.9 0.2 0.2 1.6
3.5 3.3 6.8 0.2 1.9 2.0
1.0 2.6 1.6 1.4
22+ years
Family Care
Setting
12.3 4.8 2.4 0.6 3.3 3.0 0.7 9.1
3.7 5.6 15.8 0.2 1.5 2.6
0.7 2.0 3.2 2.2
0-21 years
9.7 4.4 2.9 0.2 1.8 1.1 0.7 4.7
9.0 5.6 12.6 0.9 4.5 4.9
3.5 2.9 4.1 1.5
22+ years
Community Residence
TABLE 6 Percent of Cases for which each Behavior was Reported by Residential Setting and Age
18.4 7.4 2.2 0.4 1.7 2.2 2.0 16.2
3.1 2.7 11.1 0.1 0.4 1.1
0.5 1.8 1.1 0.9
0-21 years
19.2 7.1 3.8 0.3 3.2 2.6 3.6 15.0
7.1 5.2 15.4 0.4 2.4 3.4
2.7 6.9 3.4 1.5
22+ yetu~
Developmental Center
¢3 q3
t-o
3.2 3.4
* *
25
Number of cases
• Number of cases insufficient to report percentages
•
745
7.0 0.7 0.0 0.0 3.5
* * * *
•
3.9 0.5 9.7 3.3
* * *
Minor behaviors Hyperactivity Stereotypic/repetitive movements Actively resists supervision Crying, temper tantrums Verbally abusive to others Wandering, roaming, nmning away Inappropriately handles bodily wastes Pica Blames others Substance abuse Other behavior (not specified) 3.0 3.2 5.8 6.4 3.6 3.4 0.1 0.2 2.4 0.3 7.5 4771
10.1 5.2 7.5 13.1 2.4 5.4 0.3 1.1 0.6 0.2 7.1 4518
2.2 1.7 3.5 5.8 4.0 2.1 0.3 0.2 1.9 0.1 5.2 2573
8.5 3.7 2.9 9.6 1.9 2.9 0.9 1.0 0.4 0.0 7.5 6~
538
12.6 7.2 9.1 13.9 8.9 9.5 2.2 1.7 3.3 0.0 8.9 2819
3.5 4.0 8.8 12.9 10.4 3.9 0.8 0.3 4.7 0.4 7.7 2~7
11.1 11.0 8.8 17.8 2.4 7.3 3.3 3.9 0.5 0.1 6.2 111~
9.8 8.5 10.2 19.1 8.3 6.5 3.1 3.6 1.7 0.2 7.8
L,o
E"
¢5
,,¢
t',,
f~
¢¢
134
John W. Jacobson
Residential Setting Variation was noted in the proportion of DD and PDD individuals reported as free of problem behavior based on residential setting. Among DD individuals, 43, 48, 63, 39, and 27% of groups in independent living, living with family, in family care, community residences, and developmental centers, respectively, had no reported behaviors. In contrast, the proportions without reported behaviors in corresponding PDD groups were 12, 10, 14, 9 and 8%. Significant variation in proportions were found among DD groups only (X 2 = 1782, df = 4, p < .001, ~b' = .26), and between DD and PDD groups within each setting (X2; df = 1, p < .001, . 14 ~< dp ~< .25). For DD groups higher incidence of problem behaviors was associated with living in community residences or developmental centers; within each setting more PDD individuals displayed these behaviors. For both children and adults the frequency of specific behaviors and total number of behaviors reported varied as a function of residential setting (Adults: Fbehavior -~- 7.3, df = 28, 112, ~I}2 = .47; Fsetti.g = 15.3 df = 4, 112, ~z = .15; Children: F~havior = 13.3, df = 28, 84, ~2 = .69: Fse,,i,g = 14.5, df = 3, 84, ~2 = .08; all p < .001). As reflected by ~z, differences in specific behavior frequency accounted for substantially more of the inter-group variance than did the total number of behaviors reported in each setting. Table 6 (n = 36,272) presents the percent of cases for which each behavior was reported in each setting.
Interactions Associated with Behavior Frequencies Three-way ANOVAs were conducted among DD and PDD groups separately for level of functioning x setting x behavior type and between DD and PDD groups x behavior type x level of functioning. Findings for behavior categories were consistent with those already noted for specific behaviors, in that significant relationships among frequencies of behaviors in categories and among settings were found for both PDD arid DD groups. In addition, the number of behaviors reported varied significantly among DD individuals across intellectual levels, but accounted for only 1 percent of the total variance. Interactions between behavior categories and level of functioning (F = 3.95, df = 9,27, p < .01, ~2 = .03) and between behavior categories and setting A (F = 5.12, df = 9, 27, p < .001, toz = .11) were noted for PDD ~roups (excluding persons in independent living). The proportion of variance (~2) accounted for by the behavior categories variable in family care settings is half that found in community residences and approximately a quarter of that found in family living and developmental center settings. Among DD groups the only significant interaction effect was for behavior categories and setting (F = 3.56, df = 9, 27, p < .01, ~2 = .04). In the comparison of DD and PDD groups, effects related to behavior category (~2 = .53) and PDD/DD group membership
Behavior and Psychiatric Impairment
135
(~2 = .34) were found, in addition to a modest behavior category x DD/PDD interaction effect ( ~ = .02). Although differences in frequencies of specific behaviors were not tested across levels of functioning some patterns emerge among adults upon inspection of Tables 5 and 6. Eleven behaviors increased in frequency as a function of increasing degrees of mental retardation and residential setting restrictiveness: disorientation to time/place, assault, property destruction, genital display, disrobing, self-injurious action, stereotypic movements, temper tantrums, wandering/roaming, handling bodily wastes, and pica. The sole additional behavior which increased in frequency with residential setting restrictiveness was coercive sexual behavior. Systematic patterns of other specific behaviors were not noted on the basis of residential setting. Behaviors which increased in incidence with more marked mental retardation included echolalia, lack of interpersonal responsiveness, and hyperactivity. In contrast, frequencies for delusions/hallucinations, suicide attempts, depression, irritability, firesetting, and blaming of others are less prominent among persons with more marked mental retardation.
Summary of Findings In brief, these analyses suggest: (1) a minority of the population surveyed display some type of problem behavior, and only 13.5% display anti-social behavior, (2) PDD individuals are more likely to display problem behaviors and to display them more frequently--especially cognitive and affective behaviors-than are DD individuals, (3) the relationship between behavior frequency and residential setting is substantially greater than that between behavior frequency and intellectual level for both DD and PDD individuals, (4) in general, more restrictive settings serve persons who display more problem behaviors, (5) more disabled DD individuals are more likely to display at least one problem behavior than are less disabled DD individuals (this relationship does not obtain among PDD individuals), and (6) the probability that an individual will be diagnosed as PDD rather than DD varies principally as a function of problem behavior category/frequency rather than intellectual level or living situation. DISCUSSION It should be noted that the reference data base is skewed toward greater disability; persons with mild pervasive intellectual problems are under-represented while severely and profoundly mentally retarded individuals are overrepresented. Furthermore, proportions of mildly or moderately mentally retarded persons with either psychiatric impairment or problem behaviors may be overestimated because many persons at these intellectual levels lacking these characteristics may not participate in specialized developmental disabilities services. This skewing compromises generalization of the projected proportion of the DD
136
John W. Jacobson
population which has a psychiatric disability. Since the highest proportion of any group with PDD is 17.7% (among adults with mild mental retardation) this may be considered the upper limit for this proportion of the entire population. When adjusted for intellectual group size (based upon the distribution of persons with mental retardation; 86.7% mild mental retardation, 10% moderate mental retardation, 3.3% severe and profound mental retardation), 13.7% of children and 17.1% of adult DD populations are estimated to have a concommitant psychiatric impairment. This estimate is slightly lower than that found elsewhere (cf. Eyman & Call, 1977; Lemkau, Tietze, & Cooper, 1942), and higher than that derived from Hill and Bruninks (1981), but generally consistent with that of Rutter, Tizard, and Whitmore (1970). It can be argued that this figure could be deflated by failure of developmental disabilities personnel to recognize psychiatric involvement. However, this has been compensated for by inclusion of persons with "undetermined or unspecified" psychiatric disability in the PDD group. The primary factors which may have deflated this estimate are low availability of psychiatric services for this population, and assimilation of some PDD individuals (not identified here) within the separate mental health services system in New York State. The extent to which these variables compromise the present estimate is unknown. Nevertheless, it is notable that only 15% of behaviors reported for non-PDD groups are classified as affective and the confounding factors cited above are probably present in epidemiological studies of PDD as well. Since PDD individuals evince less marked mental retardation than do DD individuals within each setting, it would appear that presence of psychiatric impairment, and associated problem behavior, may mediate placement practices. However, in light of the correlational nature of the analyses, probable variation in the availability of psychiatric services across living situations, and relationships of intellectual functioning to living situation, the differences in proportions of recognized psychiatric disability across settings are not readily interpretable. In reviewing the problem behavior data it should be noted that even among groups which are most likely to display problem behaviors (i.e., persons with profound mental retardation and those in developmental centers), many are considered not to display behavior hindering placement or service delivery (35% and 28%, respectively). The data portray a population which is less actively problematic than some recent literature (cf. Eyman & Call, 1977), and public stereotypes would suggest. When sample values are adjusted using the same logic as that for psychiatric impairment, 47.7% of the DD population are estimated to display some type of problem behavior. Inspection of behaviors associated with higher or lower levels of functioning suggests that a major proportion of the differences may be attributed to difference in behavioral repertoire; less disabled persons may have language skills permitting them to insult others or evince delusional activity, or the intellectual skills required to purposely attempt suicide or abuse controlled substances. However,
Behavior and Psychiatric Impairment
137
since the DDIS protocol permits recording of only three problem behaviors, the extent to which repertoire is represented in these data is very limited. The present analyses suggest that natural family, family care, and community residence settings have been able to serve a cohort of PDD individuals who appear to have more frequent problem behaviors than some persons remaining in developmental centers. Possibly the personalized care found within these settings permits some persons with more frequent problem behaviors to avoid institutionalization. Such interpretations, however, are highly speculative for the same reasons as those noted regarding generalizations about placement practices. While it has been stated that the prognosis for successful community placement for people with behavior problems is guarded at best (see Sutter, Mayeda, Call, Yanagi, & Lee, 1980), other studies have suggested that personal characteristics-inclusive of problem behavior--are not adequate in themselves for prediction of adaptive functioning in group homes (Hull & Thompson, 1980). Furthermore, problem behavior analyses have, in general, focused upon behavior management problems posed by persons in institutions and group homes, without relating the level of problem behavior to that tolerated in other community and noninstitutional settings. The number of persons presenting behavior management problems now residing in group homes (or that are targeted for such placement) may be one measure of the character of at least one cohort of individuals appropriately placed in these settings, rather than a firm discriminant of success or failure. Studies have not demonstrated absence of the problem behaviors (to which failure in placement is attributed) among successfully placed persons. It is possible that failure of a program setting to address these problem behaviors, rather than the presence of the behaviors in sufficient magnitude and variety, is the determinant of success or failure. A comprehensive description of the intervention practices and discrete goals and objectives of service within group homes, and relationships of these both to resident characteristics and placement success, is sorely needed.
Acknowledgement--The editorial assistance and conceptual guidance of Drs. Matthew Janicki, Robert Lubin and Allen Schwartz of the NYS Office of Mental Retardation and Developmental Disabilities and Dr. James Mulick of the Rhode Island Child Development Center in the development of this report is gratefully acknowledged.
REFERENCE NOTES 1. Janicki, M. P., & Jacobson, J. W. New York's needs assessment and developmental disabilities: Preliminary report (Technical Monograph #78-10). Albany: OMRDD, 1979. 2. Janicki, M. P., & Jacobson, J. W. The character of developmental disabilities in New York State. International Journal of Rehabilitation Research, 1982, 5 (in press).
138
John W. Jacobson
REFERENCES American Psychiatric Association, Diagnostic and Statistical Manual, DSM-II. Washington, D.C.: American Psychiatric Association, 1968. Bjaanes, A. T., Butler, E. W., & Kelly, B. R. Placement type and client functioning level as factors in provision of services aimed at increasing adjustment. In R. H. Bruninks (Ed.), Residential services and community adjustment. Washington, D.C.: American Association on Mental Deficiency, 1980. Bortbwick, S., Meyers, C. E., & Eyman, R. K. Comparative adaptive and maladaptive behavior of mentally retarded clients of five residential settings in three western states. In R. H. Bruininks, C. E. Meyers, B. B. Sigford and K. C. Lakin (Eds.)j Deinstitutionalization and community adjustment of mentally people. Washington, D.C.: American Association on Mental Deficiency, 1981. Chess, S. Emotional problems in mentally retarded children. In F. J. Menalascino (Ed.), Psychiatric approaches to mental retardation. New York: Basic Books, 1970. Clark, M. J. I. A community placement program for the mentally retarded. American Journal of Mental Deficiency, 1959, 64, 548-555. Cohen, J. Statisticalpower analysis for the behavioral sciences. New York: Academic Press, 1969. Eagle, E. Prognosis and outcome of community placement of institutionalized retardates. American Journal of Mental Deficiency, 1967, 72, 232-243. Eyman, R. K., & Call, T. Maladaptive behavior and community placement of mentally retarded persons. American Journal of Mental Deficiency, 1977, 82, 137-144. Heal, L. W., Novak, A. R., Sigelman, C. K., & Switsky, H. N. Characteristics of community residential facilities. In A. R. Novak & L. W. Heal (Eds.), Integration of developmentally disabled individuals into the community. Baltimore: Paul H. Brooks, 1980, 45-57. Hill, B. K., & Bruninks, R. H. Physical and behavioral characteristics and maladaptive behavior of mentally retarded people in residential facilities. Minneapolis, MN: University of Minnesota, Department of Psychoeducational Studies, 1981. Hull, J. T., & Thompson, J. C. Predicting adaptive functioning of mentally retarded persons in community settings. American Journal of Mental Deficiency, 1980, 85, 253-261. Keppel, G. Design and analysis: A researcher's handbook. Englewood Cliffs: Prentice-Hall, 1973. Landesman-Dwyer, S., Schuckit, J. J., Keller, L. S., & Brown, T. R. A prospective study of client needs relative to community placement. In P. Mittler (Ed.), Research to practice in mental retardation: Care and intervention (Vol. I). Baltimore: University Park Press, 1977. Lemkau, P., Tietze, C., & Cooper, M. Mental hygiene problems in an urban district. Mental Hygiene, 1942, 26, 275-288. Menalascino, F. J. Emotional disturbance and mental retardation. American Journal of Mental Deficiency, 1965, 70, 248-256. Menalascino, F. J. The facade of mental retardation. American Journal of Psychiatry, 1966, 122, 1227-1235. Mulick, J. A., & Schroeder, S. R. Research relating to management of anti-social behavior in mentally retarded persons. Psychological Record, 1980, 30, 397-417. Nihira, L., & Nihira, K. Jeopardy in community placement. American Journal of Mental Deficiency, 1975, 79, 538-544. Phillips, I., & Williams, N. Psychopathology and mental retardation: A study of 100 mentally retarded children. I. Psychopathology. American Journal of Psychiatry, 1975, 132, 1265-1271. Rutter, M., Tizard, J., & Whitmore, K. Education, health and behavior. New York: Wiley, 1970. Schroeder, S. R., Mulick, J. A., & Schroeder, C. S. Management of severe behavior problems of the retarded. In R. R. Ellis (Ed.), Handbook of Mental Deficiency: Psychological theory and research (2nd ed.). Hillsdale, NJ: Lawrence Edbaum, 1979.
Behavior and Psychiatric Impairment
139
Sutter, P., Mayeda, T., Call, T., Yanagi, G., & Yee, S. Comparison of successful and unsuccessful community-placed mentally retarded persons. American Journal of Mental Deficiency, 1980, 85, 262-267. Szymanski, L. S. Psychiatric diagnostic evaluation of mentally retarded individuals. Journal of the American Academy of Child Psychiatry, 1977, 16, 67-87. Taylor, J, R. A comparison of the adaptive behavior of retarded individuals successfully and unsuccessfully placed in group living homes. Education and Training of the Mentally Retarded, 1976, 11, 56-64. Vogel, W., Kun, K. J., & Mesborer, E. Determinants of institutional release and prognosis in mental retardates. Journal of Abnormal Psychology, 1969, 74, 685-692. Webster, T. G. Unique aspects of emotional development in mentally retarded children, In F. J. Menalascino (Ed.), Psychiatric approaches to mental retardation. New York: Basic Books, 1970. Windle, C. D., Stewart, E., & Brown, S. J. Reasons for community failure of released patients. American Journal of Mental Deficiency, 1961, 66, 213-217. Wolfensberger, W. Twenty predictions about the future of residential services in mental retardation. Mental Retardation, 1969, 7, 51-54.
0270 - 3092/82/020121- 19503.00/0 Copyright © 1982 Pergamon Press Ltd
Problem Behavior and Psychiatric Impairment Within a Developmentally Disabled Population I: Behavior Frequency John W. lacobson New York State Office of Mental Retardation and Developmental Disabilities
This report summarizes information about problem behavior and psychiatric impairment in a population of over 30,000 individuals receiving developmental disabilities services. Teenage and adult individuals displayed more problem behaviors than young children or the elderly, more markedly mentally retarded individuals were more likely to display problem behavior, individuals in less restrictive residential settings displayed less problem behavior than those in more restrictive settings, and persons with psychiatric impairment displayed more frequent problems than persons without psychiatric impairment. The proportion of developmentally disabled persons with a psychiatric impairment was positively associated with presence of problem behaviors classified as affective or cognitive. Implications for community placement and further research are addressed.
During the past decade the trend toward development of small residential settings and the adoption of institutional admission diversion policies has been accompanied by decreased use of large institutions for persons with developmental disabilities (DD). It has been projected that, during the next 10 years, the small (7 to 15 person) group home will constitute the primary living alternative for DD individuals placed out-of-home (Wolfensberger, 1969). However, much of the growth in community residential living alternatives has resulted from the return of relatively capable institutional residents to the community and it would Requests for reprints should be addressed to: John W. Jacobson, Bureau of Program Research and Planning, New York State Office of Mental Retardation and Developmental Disabilities, 44 Holland Avenue, Albany, New York 12229. 121
122
John W. Jacobson
appear that many future entrants to community residential programs will probably be more seriously or multiply disabled (Heal, Novak, Sigelman, & Switsky, 1980). If repatriation is to continue, the community service system will have to accommodate increasingly disabled individuals (both in regard to multiple handicaps and problem behavior) and continue to accommodate individuals who have never been institutionalized. An extensive literature has documented the difficulties that arise in community placement of multiply handicapped and behavior problem individuals (Bjaanes, Butler, & Kelly, 1980; Clark, 1959; Eagle, 1967; Nihira & Nihira, 1975; Taylor, 1976; Vogel, Kun, & Meshorer, 1969; Windle, Stewart, & Brown, 1961). These difficulties have helped to maintain interest in the practical management of problem behavior (see Mulick & Schroeder, 1980; Schroeder, Mulick, & Schroeder, 1979). Eyman and Call (1977), in a survey of 6,870 persons with mental retardation, found that, in general, more marked behavior problems are associated with greater degrees of retardation, and behavior problems are more frequently noted within institutions than in community settings. Although Eyman and Call reviewed only 11 behaviors the estimated prevalence of some of these is alarmingly high. For example, overall rates of 28% and 15% were obtained for the incidence of aggressive and self-injurious behaviors. These findings are in contrast with those of Landesman-Dwyer, Schuckit, Keller, and Brown (1977) who grouped 10,000 disabled persons into functional skills classes. They found no clear-cut relationship of problem behavior to functioning level, and as many as 50% of the members of any class displayed no problem behavior, or what the authors regarded as mild problem behavior. More recently, further discussion of the behaviors reviewed by Eyman and Call (1977) has been presented by Borthwick, Meyers, and Eyman (1981), and Hill and Bruininks (1981) have collected information about eight problem behaviors among 2,486 persons residing in public and private residential programs nationally as part of a more comprehensive investigation. Notably, 52.7% of community residential facility occupants and 40.3% of public residential facility occupants were reported as displaying none of these eight behaviors. A separate, but related issue concerns the extent of affective dysfunction among persons who also have a developmental disability. Prevalence estimates of psychiatric impairment range from 31% (Menalascino, 1965. 1966) to 100% (Webster, 1970) of cases, with intermediate proportions noted by others (Chess, 1970; Phillips & Williams, 1975; Szymanski, 1977). Generalizing from these reports is difficult because all are based upon data from children referred to clinics for psychiatric assessment. In contrast, Hill and Bruninks (1981) found that, among 1,486 DD residential program occupants, only 1.1% were reported to have behavior disorders. If the potential impact of problem behavior and psychiatric impairment upon community placement of developmentally disabled persons is to be understood, further attention to these factors is warranted. The present report summarizes
Behavior and Psychiatric Impairment
123
data regarding problem behavior, psychiatric impairment, level of intellectual functioning, and residential placement among developmentally disabled individuals in New York State. METHOD
Population The sample for this study consisted of 30,578 mentally retarded individuals residing either independently in the community, with their families, in family foster care, in community residences (group homes) or developmental centers (state-operated institutions), and for whom a current classification of intellectual functioning was available. Of this group 3,555 (11.6% overall; 9.8% of children and 12.4% of adults) had been classified as having a psychiatric disability. For purposes of analysis the behavior of persons with both psychiatric and developmental disabilities (termed PDD) and those with developmental disabilities solely (termed DD) was considered separately. Demographically, DD and PDD individuals were quite similar. Data on the age, gender, disability, and psychiatric impairment distributions of these groups are presented in Table 1.
TABLE 1 Percent Distribution of Population Characteristics
Developmentally Psychiatric/Developmentally Disabled Disabled (PDD) Age in Years 0-4 5-20 21-44 45-64 65 + Gender Male Female Disabilities Autism Cerebral palsy Epilepsy Mental retardation Other neurological impairments Psychiatric Impairments Psychosis Non-psychotic organic brain syndrome Personality disorder Other conditions Number of cases
4 25 48 18 5
1 25 51 19 4
55 45
60 40
1 13 22 100 14
5 5 26 100 17
0 0 0 0 27023
28 14 18 40 3555
124
John W. Jacobson
In reviewing tabular results, it will be noted that Table n's will vary. These n's reflect analyses of data at different points in a survey process (as the data base used continues to grow, information on more cases becomes available). Table n's which are either smaller or larger than those in Table 1 reflect groups which are equivalent in level of functioning and other characteristics to the Table 1 group. Instrument
Data on problem behavior and psychiatric impairment were extracted from the data base for the New York Developmental Disabilities Information Survey (DDIS) (Janicki & Jacobson, Note 1, Note 2). The DDIS is a comprehensive, population-based survey of individuals with developmental disabilities in New York State. Among the data elements within the DDIS is an item recording a maximum of three problem behaviors and general frequency for each behavior. Coding requires entry of values for the absence, as well as the presence, of such behavior. Of all problem behaviors reported, 69% occur weekly or daily and 18% occur monthly. Behaviors recorded are therefore a reflection of frequently occurring problems, rather than indications of past actions. Other items in the survey booklet collect information about level of intellectual functioning, current residential setting, and the presence of single and multiple diagnosed psychiatric impairment. Entry of this data is dependent upon the presence of substantiating material within the individual program plan. Protocols are completed by clinical staff with experience in the provision of DD services. Behaviors Addressed
The 29 behaviors selected for this report constitute the list of possible behaviors which may be indicated within the DDIS as obstacles to placement or provision of services (see section on presence of psychiatric impairment). For the purpose of analysis these behaviors have been grouped into four categories: cognitive, affective, major, and minor. Cognitive behaviors are those which have a likelihood of occurrence in instances of selective neurological deficit or psychosis. Affective behaviors are those which are associated with other psychiatric impairments and interpersonal immaturity. Major behaviors are violent, destructive, and antisocial acts which not only pose a serious barrier to community placement and maintenance but are also generally legally proscribed. (Minor behaviors include all those listed in Table 3 under the section presence of psychiatric impairment, which clinical experience and research suggest should occur in the target population.) The distinction between major and minor is intended to separate those behaviors which pose more versus less marked barriers to community placement. Differences in potential for amelioration should not be inferred between the two categories. Many "minor" behaviors, such as pica,
Behavior and Psychiatric Impairment
125
may be both hazardous to an individual's health and resistant to intervention. While the list of behaviors is brief, it appears of sufficient diversity; "other"/ unspecified problem behavior is reported for only 7.5% of all cases.
Procedure Group comparisons were performed using chi-squares and analyses of variance. With large sample sizes, such as those used in this report, it is possible to obtain statistically significant X 2 and F values which nonetheless represent minor differences between groups. For this reason, an additional parameter was computed for each analysis. For chi-squares the qualifying parameter was either ~b, the fourfold point correlation coefficient (2 x 2 or df = 1 contingency tables), or qb', Cramers's phi, a generalization of d~ to tables with other df (see Cohen, 1969). While not interpretable as a product-moment correlation, unlike a contingency coefficient it does have a range from 0 to 1 regardless of degrees of freedom, and may be used as an estimate of relationship. For each significent F value an omega-squared (~2) was computed. Omegasquared, in this application, reflects the proportion of variance among groups accounted for by each variable (see Keppel, 1973).
RESULTS
Population In Table 2 some variation in population distribution is apparent. As would be expected, residents of family care, community residences, and developmental centers evince lower levels of intellectual functioning than do persons living independently or with their families (X 2 = 9260, df = 12, p < .001, ~b' = .32). The proportion of persons with a psychiatric impairment varies as a function of setting (X 2 = 156, df = 4, p < .001, d~' = .07), level of intellectual functioning (X 2 = 336, df = 3, p < .001, ~b' = . 10), and age (X 2 = 40, df = l, p < .001, qb = .04). The proportion of persons with such impairment ranges from 22% of persons with normal intelligence to seven percent of persons with profound mental retardation. Thirteen percent of persons living with family, 14% in independent living, five percent in family care, 14% in community residences, and 12% in developmental centers evince psychiatric impairment. Finally, intellectual level distribution differed between DD and PDD groups living with family (X 2 = 19.5, df = 3, p < .001, ~ ' = .04), in family care (X 2 = 22.6. df = 3, p < .001, ~b' = .08), in community residences (X 2 = 47.5, df = 3, p < .001, ~b' = . 12), and in developmental centers (X: = 1549, df = 3, p < .001, qb' = .33). In general, DD groups evinced more marked
htekCNd
0 0 33 3
0 - 13 23
26 2
3
69
423
Number of cases (22 +)
4206
9 ----__
21
38
32
24 32 32 12 2424
41 32 17 10 565
149
7
31
28
34
4 25
32
20
35
19
20
44
PDD
655
12 33
32
DD
Family Care _
34
PDD
15 21 -------___ 540 3918
21
29
29
DD
Living with Family
*Percentages are percent of column totals within DDiPDD and setting
2
- 1
Profound mental retardation
Severe mental retardation
72
71 25
Moderate mental retardation
Years
Mild mental retardation
Persons 22+
Number of cases (O-21)
Profound mental retardation
Severe mental retardation
67
51
PDD
30
DD
Independent Living
Moderate mental retardation
Functioning
Mild mental retardation
Persons O-21 Years
Level of
2406
13
26
31
30
469
32
28
23
17
DD
413
7
18
30
44
69
21
19
32
28
PDD
Community Residence
2-l 35
24 60 96901504
15 23
41 218
73 2749
5
28
18
11
9 22
I
PDD
2
DD
Developmental Center
Level, and Setting*
Residential Setting
TABLE 2 Percent of Persons as a Function of Age, Intekctual
-- 35 19149
24
22
18
1814
39
22
21
18
DD
Overall
2700
24
23
26
27
855
22
21
30
21
PDD
Behavior and Psychiatric Impairment
127
degrees of mental retardation than the PDD groups in these settings; this was most apparent in community residences and developmental centers.
Presence of Psychiatric Impairment Comparisons were drawn between children and adults with and without psychiatric impairment (see Table 3). Among children problem behaviors were distributed differently and were more frequent in the PDD group (Fbehavior = 7.0, df = 28, 28, p < .001,~2 = .65;FDD/PDD = 34.7, df = 1,28, p < .001, t~2 = . 13). Among adults the PDD group also evinced more frequent and different problem behaviors (F~havio~ = 8.0, df = 28, 28, p < .001, ~2 = .69; FDD/PDD = 32.2, df = 1, 28, p < .001, ~2 = .11). Differences in distribution and overall frequency of behaviors was also apparent between DD children and adults (F~,avior = 22.3, d f = 28, 28, p < .001,~2 = .90;Fa~e = 7.3, d f = 1 , 2 8 , p < .001, t~2 = .01). Differences in the distribution of behaviors were also found between PDD children and adults (Fbehav~o~ ----- 12.3, df = 28, 28, p < A .001, co2 = .84), but discrepancies in the total number of behaviors displayed were non-significant. These findings are consistent with those of 3-way A N O V A wherein behavior frequency varied as a function of the behavior (~2 = .71) and DD/PDD group membership (t~2 = . 10), but not as a function of age. Interaction effects related to these variables were not noted. Comparisons of the PDD and DD groups without reference to age disclosed that behaviors in each category were more likely to occur among PDD individuals. This relationship was most marked for cognitive and affective behaviors (XZ¢og,,~vo = 362, ~b = .23; X2~ffe~,~ = 1517, ~b = .46; X2~jo~ = 69, ~b = .09; X2mi,o~ = 238, d~ = .18; all df = 1, a l l p < .001).
Age and Level of Intellectual Functioning Data in Table 4 (n = 32,427) are arrayed without reference to psychiatric impairment. Differences in proportions of behavior type were present across age groups within each level of functioning (X 2, all df = 9, all p < .001, with ~b' ranging from .07 for profound mental retardation to .01 for severe mental retardation). In general, persons age 0 - 2 1 displayed fewer cognitive and affective problems, and more minor problems than persons age 22 and older. Additionally, persons age 0 - 1 2 and 60 or older displayed fewer major behaviors than persons age 1 3 - 5 9 . Differences in proportions of age groups with problem behaviors were also present at each level of functioning (X 2, all df = 3, allp < .001, with d~' ranging from .24 for profound mental retardation to .08 for mild mental retardation). Persons age 0 - 1 2 were less likely to display problem behavior than older persons, particularly those age 2 2 - 5 9 .
128
John W. Jacobson TABLE 3 Percent of Cases for which each Behavior was Reported for Developmentally Disabled Persons, Psychiatric/Developmentally Disabled Persons, and Entire Data File Disability Group Developmentally Disabled
Psychiatric/ Developmentally Disabled
0-21 years
22+ years
0-21 years
22+ years
All
Cognitive problems Delusions/hallucinations Disorientation to time/place Perseveration Echolalia
0.4 1.7 2.1 1.3
1.4 4.0 2.9 1.3
4.7 6.1 5.8 4.6
10,3 9.0 5.4 2.1
2.2 3.8 2.8 1.3
Affective problems Extreme mood changes Appropriate affect not displayed Lack of interpersonal responsiveness Suicide threats/attempts Depression Extreme irritability
2.3 3.4 9.1 0.1 0.3 1.1
5.2 4.1 10.8 0.3 2.0 2.7
10.2 12.5 22.3 0.8 4.0 3.6
14.0 11.0 20.7 1.9 9.1 7.3
5.6 4.9 12.3 0.4 2.9 2.9
Major behaviors Physical assault upon others Property destruction Property theft Fire setting/attempts Coercive sexual behavior Inappropriate genital display Inappropriate public disrobing Self-injurious action
8.5 3.7 1.2 0.2 0.9 1.1 0.9 7.7
11.3 4.4 2.8 0.2 1.5 1.5 1.9 9.3
21.5 9.2 2.3 1.2 2.2 2.5 1.6 15.3
18.5 6.7 3.2 0.5 1.3 2.3 2.3 10.6
10.9 4.3 2,4 0.4 1.4 1.4 1.5 8.2
Minor behaviors Hyperactivity Stereotypic/repetitive movements Actively resists supervision Crying, temper tantrums Verbally abusive to others Wandering, roaming, running away Inappropriately handles bodily wastes Pica Blames others Substance abuse Other behavior (not specified)
9.3 7.0 7.0 13.8 2.4 5.7 1.5 1.9 0.7 0.1 6.8
5.4 5.6 7.7 13.2 6.3 4.5 1.8 1.9 2.2 0.2 7.2
21.0 8.7 13.5 20.7 6.8 9.8 1.6 3.0 0.9 0.2 8.1
10.1 6.9 12.9 16.7 12.2 7.0 1.9 2.1 3.4 0.7 7.9
7.4 5.8 8.1 13.7 5.9 4.9 1.6 1.9 1.7 0.4 7.5
Number of cases
7873
19149
855
2700
32112'
Overall*
*Includes 1535 additional persons residing in other settings
Level of lntellectual Functioning
Considerable variation was apparent in proportions of DD and PDD individuals reported as free of problem behavior based upon level of intellectual functioning. For example, among developmentally disabled individuals 54, 48, 40,
Behavior and Psychiatric Impairment
129
TABLE 4 Percentage of Behavior Problem Types as a Function of Age and Intellectual Level
Age within Level of Intellectual Functioning
n (Cases)
Percent without Problem Behaviors
Cognitive
Mild mentalretardation 0-12 13-21 22-59 60+
708 818 4024 641
60 45 50 57
11 5 8 18
14 26 35 32
14 19 14 11
61 50 43 39
Moderate mentalretard~ion 0-12 13-21 22-59 60+
640 1163 4866 632
53 40 45 56
8 7 10 13
19 22 27 32
14 24 20 13
59 47 44 58
Severe mentalretardmion 0-12 13-21 22-59 60+
652 1208 4754 841
46 35 36 42
5 6 8 12
15 14 20 29
17 30 26 19
63 50 44 40
Profound mentalretard~ion 0-12 13-21 22-59 60+
1056 2539 7175 710
62 43 25 33
4 4 7 12
19 15 17 26
22 33 33 22
55 48 43 40
Behavior Type* Affective Major
Minor
*Among individuals with a problem behavior reported only
and 35% o f groups with mild retardation, moderate retardation, severe retardation, and profound retardation, respectively, had no reported behaviors (X 2 = 576, df = 3, p < .001, ~b' = . 15). In comparison, the proportions without reported behavior in corresponding P D D groups were 14, 12, 9 and 12% (X 2 = 10.3, df = 3, p < .02, ~b' = .05). In s u m m a r y , 38.6% of D D and 9 . 8 % of P D D individuals had no reported p r o b l e m behaviors; P D D individuals were significantly more likely to display problem behavior (X 2 = 927, df = 1, p < .001, ~b = .29). These differences (X 2, df = 12, p < .001, . 12 ~< d~ ~< .29) were present at each level of intellectual functioning. Frequencies of specific behaviors differed significantly across levels of functioning for both children and adults (Fchildren = 15.6, t~2 = .78; Fadalts = 8.7, ~z = .62, both df = 28, 84, both p < .001), but the total n u m b e r of behaviors reported differed across intellectual levels for adults alone (F = 6.1, df = 3, 84, p < .01, ~2 = .04), although this accounted for only 4% of the total intergroup variance. Table 5 presents the percent of cases for which each b e h a v i o r was reported by level of intellectual functioning, without reference to psychiatric impairment.
1.4 1.4 2.4 1.5
3.8 4.2 8.9 0.4 2.0 1.4
5.5 2.1 1.9 0.7 1.5 O. 1 0.1 1.8
Cognitive problems Delusions/hallucinations Disorientation to time/place Perseveration Echolalia
Affective problems Extreme mood changes Appropriate affect not displayed Lack of interpersonal responsivaness Suicide threats/attempts Depression Extreme irritability
Major behaviors Physical assault upon others Property destruction Property theft Fire setting/attempts Coercive sexual behavior Inappropriate genital display Inappropriate public disrobing Self-injurious behavior 5.5 1.8 2.5 0.4 1.7 0.6 0.3 2.9
7.2 5,5 10.6 1.4 6.2 4.1
3.4 1.9 2.0 0.5
8.0 4.0 2.2 0.6 1.4 1.1 0.2 3.4
3.9 5.8 9.7 0.2 1.2 1.7
0.9 2.3 3.6 2.4
8.5 3.3 2.5 0.3 1.5 0.7 0.4 3.4
7.3 4.8 10.0 0.6 3.6 4.0
3.3 2.4 3.4 0.9
22+ years
0-21 years
0-21 years
22+ years
Moderate Mental Retardation
Mild Mental Retardation
12.5 5.7 0.9 0.2 1.1 1.5 1.5 9.1
4.6 4.1 10.5 0.1 0.2 1.7
0.8 2.0 3.4 2,6
0-21 years
13.9 5.3 3.4 0.2 1.6 1.1 1.3 6.4
7.2 4.5 12.4 0.2 2.4 2.7
2.8 4.4 3.8 2.5
22+ years
Severe Mental Retardation
TABLE 5 Percent of Cases for which each Behavior was Reported by Intellectual Level and Age
11.2 4.6 0.8 O. 1 0.5 1.8 1.5 14.3
3.2 3.6 11.6 0.0 0.2 1.2
0.4 2.3 1.2 0.8
O- 21 years
17.3 6,8 2.9 O. 1 1.7 3.2 4.5 18.0
4.7 5.0 16.8 0.1 0.9 2.3
1.3 7.6 3.2 1.9
22 + years
Profound Mental Retardatiofi
7.0 1.9 9.6 11.5 6.0 5.2 0.4 0.7 1.5 0.4 13.2
1627
Minor behaviors Hyperactivity Stereotypic/repetitive movements Actively resists supervision Crying, temper tantrums Verbally abusive to others Wandering, roaming, running away Inappropriately handles bodily wastes Pica Blames others Substance abuse Other behavior (not specified)
Number of cases
4163
2.3 1.6 7.7 8.0 9.5 2.9 0.2 0.2 4.2 0.8 7.6 1930
8.8 4.6 7.5 13.6 5.2 6.1 0.3 0.6 1.3 0.1 7.9 5010
3.7 2.6 8.1 11.3 9.8 3.5 0.4 0.2 3.3 0.2 6.7 1876
13.5 8.7 9.0 17.6 1.8 7.7 1.4 2.4 0.4 0.1 6.4 5249
5.5 4.3 8.5 16.1 8.4 4.7 0.9 0.8 2.5 0.1 7.0 3295
9.5 10.4 6.0 14.7 0.4 5.7 2.8 3.4 0.2 0.0 6.3 7427
11.3 8.7 16.7 2.7 6.9 4.2 4.8 0.5 0.2 7.8
11.2
~r'
"u
g-
* * * * * * * * * * * * * * * * * *
Cognitive problems Delusions/Hallucinations Disorientation to time/place Perseverafion Echolalia
Affective problems Extreme mood changes Appropriate affect not displayed Lack of interpersonal responsiveness Suicide threats/attempts Depression ExUeme irritability
Major behaviors Physical assault upon others Property destruction Property theft F'tre setting/attempts Coercive sexual behavior Inappropriate genital display Inappropriate public disrobing Self-injurious action
0-21 years
2.3 1.4 1.8 0.5 0.6 0.1 0.0 1.2
7.8 3.9 8.2 3.0 10.4 3.9
2.9 1.0 0.6 0.0
22+ years
Independent Living
4.9 2.4 0.7 0.3 0.4 0.6 0.4 4.2
3.2 5.4 10.0 0.2 0.9 1.5
0.1 2.4 3.4 2.0
0-21 years
3.6 1.1 0.9 0.1 0.7 0.5 0.2 1.7
4.5 5.1 11.5 0.3 3.1 2.7
2.4 2.0 3.3 1.2
22+ years
Living with Parents
2.9 2.2 1.5 0.3 0.7 0.4 0.3 2.4
1.8 2.1 6.2 0.0 0.3 0.3
0.4 1.3 1.5 2.2
0-21 years
2.8 2.2 2.4 0.2 0.9 0.2 0.2 1.6
3.5 3.3 6.8 0.2 1.9 2.0
1.0 2.6 1.6 1.4
22+ years
Family Care
Setting
12.3 4.8 2.4 0.6 3.3 3.0 0.7 9.1
3.7 5.6 15.8 0.2 1.5 2.6
0.7 2.0 3.2 2.2
0-21 years
9.7 4.4 2.9 0.2 1.8 1.1 0.7 4.7
9.0 5.6 12.6 0.9 4.5 4.9
3.5 2.9 4.1 1.5
22+ years
Community Residence
TABLE 6 Percent of Cases for which each Behavior was Reported by Residential Setting and Age
18.4 7.4 2.2 0.4 1.7 2.2 2.0 16.2
3.1 2.7 11.1 0.1 0.4 1.1
0.5 1.8 1.1 0.9
0-21 years
19.2 7.1 3.8 0.3 3.2 2.6 3.6 15.0
7.1 5.2 15.4 0.4 2.4 3.4
2.7 6.9 3.4 1.5
22+ yetu~
Developmental Center
¢3 q3
t-o
3.2 3.4
* *
25
Number of cases
• Number of cases insufficient to report percentages
•
745
7.0 0.7 0.0 0.0 3.5
* * * *
•
3.9 0.5 9.7 3.3
* * *
Minor behaviors Hyperactivity Stereotypic/repetitive movements Actively resists supervision Crying, temper tantrums Verbally abusive to others Wandering, roaming, nmning away Inappropriately handles bodily wastes Pica Blames others Substance abuse Other behavior (not specified) 3.0 3.2 5.8 6.4 3.6 3.4 0.1 0.2 2.4 0.3 7.5 4771
10.1 5.2 7.5 13.1 2.4 5.4 0.3 1.1 0.6 0.2 7.1 4518
2.2 1.7 3.5 5.8 4.0 2.1 0.3 0.2 1.9 0.1 5.2 2573
8.5 3.7 2.9 9.6 1.9 2.9 0.9 1.0 0.4 0.0 7.5 6~
538
12.6 7.2 9.1 13.9 8.9 9.5 2.2 1.7 3.3 0.0 8.9 2819
3.5 4.0 8.8 12.9 10.4 3.9 0.8 0.3 4.7 0.4 7.7 2~7
11.1 11.0 8.8 17.8 2.4 7.3 3.3 3.9 0.5 0.1 6.2 111~
9.8 8.5 10.2 19.1 8.3 6.5 3.1 3.6 1.7 0.2 7.8
L,o
E"
¢5
,,¢
t',,
f~
¢¢
134
John W. Jacobson
Residential Setting Variation was noted in the proportion of DD and PDD individuals reported as free of problem behavior based on residential setting. Among DD individuals, 43, 48, 63, 39, and 27% of groups in independent living, living with family, in family care, community residences, and developmental centers, respectively, had no reported behaviors. In contrast, the proportions without reported behaviors in corresponding PDD groups were 12, 10, 14, 9 and 8%. Significant variation in proportions were found among DD groups only (X 2 = 1782, df = 4, p < .001, ~b' = .26), and between DD and PDD groups within each setting (X2; df = 1, p < .001, . 14 ~< dp ~< .25). For DD groups higher incidence of problem behaviors was associated with living in community residences or developmental centers; within each setting more PDD individuals displayed these behaviors. For both children and adults the frequency of specific behaviors and total number of behaviors reported varied as a function of residential setting (Adults: Fbehavior -~- 7.3, df = 28, 112, ~I}2 = .47; Fsetti.g = 15.3 df = 4, 112, ~z = .15; Children: F~havior = 13.3, df = 28, 84, ~2 = .69: Fse,,i,g = 14.5, df = 3, 84, ~2 = .08; all p < .001). As reflected by ~z, differences in specific behavior frequency accounted for substantially more of the inter-group variance than did the total number of behaviors reported in each setting. Table 6 (n = 36,272) presents the percent of cases for which each behavior was reported in each setting.
Interactions Associated with Behavior Frequencies Three-way ANOVAs were conducted among DD and PDD groups separately for level of functioning x setting x behavior type and between DD and PDD groups x behavior type x level of functioning. Findings for behavior categories were consistent with those already noted for specific behaviors, in that significant relationships among frequencies of behaviors in categories and among settings were found for both PDD arid DD groups. In addition, the number of behaviors reported varied significantly among DD individuals across intellectual levels, but accounted for only 1 percent of the total variance. Interactions between behavior categories and level of functioning (F = 3.95, df = 9,27, p < .01, ~2 = .03) and between behavior categories and setting A (F = 5.12, df = 9, 27, p < .001, toz = .11) were noted for PDD ~roups (excluding persons in independent living). The proportion of variance (~2) accounted for by the behavior categories variable in family care settings is half that found in community residences and approximately a quarter of that found in family living and developmental center settings. Among DD groups the only significant interaction effect was for behavior categories and setting (F = 3.56, df = 9, 27, p < .01, ~2 = .04). In the comparison of DD and PDD groups, effects related to behavior category (~2 = .53) and PDD/DD group membership
Behavior and Psychiatric Impairment
135
(~2 = .34) were found, in addition to a modest behavior category x DD/PDD interaction effect ( ~ = .02). Although differences in frequencies of specific behaviors were not tested across levels of functioning some patterns emerge among adults upon inspection of Tables 5 and 6. Eleven behaviors increased in frequency as a function of increasing degrees of mental retardation and residential setting restrictiveness: disorientation to time/place, assault, property destruction, genital display, disrobing, self-injurious action, stereotypic movements, temper tantrums, wandering/roaming, handling bodily wastes, and pica. The sole additional behavior which increased in frequency with residential setting restrictiveness was coercive sexual behavior. Systematic patterns of other specific behaviors were not noted on the basis of residential setting. Behaviors which increased in incidence with more marked mental retardation included echolalia, lack of interpersonal responsiveness, and hyperactivity. In contrast, frequencies for delusions/hallucinations, suicide attempts, depression, irritability, firesetting, and blaming of others are less prominent among persons with more marked mental retardation.
Summary of Findings In brief, these analyses suggest: (1) a minority of the population surveyed display some type of problem behavior, and only 13.5% display anti-social behavior, (2) PDD individuals are more likely to display problem behaviors and to display them more frequently--especially cognitive and affective behaviors-than are DD individuals, (3) the relationship between behavior frequency and residential setting is substantially greater than that between behavior frequency and intellectual level for both DD and PDD individuals, (4) in general, more restrictive settings serve persons who display more problem behaviors, (5) more disabled DD individuals are more likely to display at least one problem behavior than are less disabled DD individuals (this relationship does not obtain among PDD individuals), and (6) the probability that an individual will be diagnosed as PDD rather than DD varies principally as a function of problem behavior category/frequency rather than intellectual level or living situation. DISCUSSION It should be noted that the reference data base is skewed toward greater disability; persons with mild pervasive intellectual problems are under-represented while severely and profoundly mentally retarded individuals are overrepresented. Furthermore, proportions of mildly or moderately mentally retarded persons with either psychiatric impairment or problem behaviors may be overestimated because many persons at these intellectual levels lacking these characteristics may not participate in specialized developmental disabilities services. This skewing compromises generalization of the projected proportion of the DD
136
John W. Jacobson
population which has a psychiatric disability. Since the highest proportion of any group with PDD is 17.7% (among adults with mild mental retardation) this may be considered the upper limit for this proportion of the entire population. When adjusted for intellectual group size (based upon the distribution of persons with mental retardation; 86.7% mild mental retardation, 10% moderate mental retardation, 3.3% severe and profound mental retardation), 13.7% of children and 17.1% of adult DD populations are estimated to have a concommitant psychiatric impairment. This estimate is slightly lower than that found elsewhere (cf. Eyman & Call, 1977; Lemkau, Tietze, & Cooper, 1942), and higher than that derived from Hill and Bruninks (1981), but generally consistent with that of Rutter, Tizard, and Whitmore (1970). It can be argued that this figure could be deflated by failure of developmental disabilities personnel to recognize psychiatric involvement. However, this has been compensated for by inclusion of persons with "undetermined or unspecified" psychiatric disability in the PDD group. The primary factors which may have deflated this estimate are low availability of psychiatric services for this population, and assimilation of some PDD individuals (not identified here) within the separate mental health services system in New York State. The extent to which these variables compromise the present estimate is unknown. Nevertheless, it is notable that only 15% of behaviors reported for non-PDD groups are classified as affective and the confounding factors cited above are probably present in epidemiological studies of PDD as well. Since PDD individuals evince less marked mental retardation than do DD individuals within each setting, it would appear that presence of psychiatric impairment, and associated problem behavior, may mediate placement practices. However, in light of the correlational nature of the analyses, probable variation in the availability of psychiatric services across living situations, and relationships of intellectual functioning to living situation, the differences in proportions of recognized psychiatric disability across settings are not readily interpretable. In reviewing the problem behavior data it should be noted that even among groups which are most likely to display problem behaviors (i.e., persons with profound mental retardation and those in developmental centers), many are considered not to display behavior hindering placement or service delivery (35% and 28%, respectively). The data portray a population which is less actively problematic than some recent literature (cf. Eyman & Call, 1977), and public stereotypes would suggest. When sample values are adjusted using the same logic as that for psychiatric impairment, 47.7% of the DD population are estimated to display some type of problem behavior. Inspection of behaviors associated with higher or lower levels of functioning suggests that a major proportion of the differences may be attributed to difference in behavioral repertoire; less disabled persons may have language skills permitting them to insult others or evince delusional activity, or the intellectual skills required to purposely attempt suicide or abuse controlled substances. However,
Behavior and Psychiatric Impairment
137
since the DDIS protocol permits recording of only three problem behaviors, the extent to which repertoire is represented in these data is very limited. The present analyses suggest that natural family, family care, and community residence settings have been able to serve a cohort of PDD individuals who appear to have more frequent problem behaviors than some persons remaining in developmental centers. Possibly the personalized care found within these settings permits some persons with more frequent problem behaviors to avoid institutionalization. Such interpretations, however, are highly speculative for the same reasons as those noted regarding generalizations about placement practices. While it has been stated that the prognosis for successful community placement for people with behavior problems is guarded at best (see Sutter, Mayeda, Call, Yanagi, & Lee, 1980), other studies have suggested that personal characteristics-inclusive of problem behavior--are not adequate in themselves for prediction of adaptive functioning in group homes (Hull & Thompson, 1980). Furthermore, problem behavior analyses have, in general, focused upon behavior management problems posed by persons in institutions and group homes, without relating the level of problem behavior to that tolerated in other community and noninstitutional settings. The number of persons presenting behavior management problems now residing in group homes (or that are targeted for such placement) may be one measure of the character of at least one cohort of individuals appropriately placed in these settings, rather than a firm discriminant of success or failure. Studies have not demonstrated absence of the problem behaviors (to which failure in placement is attributed) among successfully placed persons. It is possible that failure of a program setting to address these problem behaviors, rather than the presence of the behaviors in sufficient magnitude and variety, is the determinant of success or failure. A comprehensive description of the intervention practices and discrete goals and objectives of service within group homes, and relationships of these both to resident characteristics and placement success, is sorely needed.
Acknowledgement--The editorial assistance and conceptual guidance of Drs. Matthew Janicki, Robert Lubin and Allen Schwartz of the NYS Office of Mental Retardation and Developmental Disabilities and Dr. James Mulick of the Rhode Island Child Development Center in the development of this report is gratefully acknowledged.
REFERENCE NOTES 1. Janicki, M. P., & Jacobson, J. W. New York's needs assessment and developmental disabilities: Preliminary report (Technical Monograph #78-10). Albany: OMRDD, 1979. 2. Janicki, M. P., & Jacobson, J. W. The character of developmental disabilities in New York State. International Journal of Rehabilitation Research, 1982, 5 (in press).
138
John W. Jacobson
REFERENCES American Psychiatric Association, Diagnostic and Statistical Manual, DSM-II. Washington, D.C.: American Psychiatric Association, 1968. Bjaanes, A. T., Butler, E. W., & Kelly, B. R. Placement type and client functioning level as factors in provision of services aimed at increasing adjustment. In R. H. Bruninks (Ed.), Residential services and community adjustment. Washington, D.C.: American Association on Mental Deficiency, 1980. Bortbwick, S., Meyers, C. E., & Eyman, R. K. Comparative adaptive and maladaptive behavior of mentally retarded clients of five residential settings in three western states. In R. H. Bruininks, C. E. Meyers, B. B. Sigford and K. C. Lakin (Eds.)j Deinstitutionalization and community adjustment of mentally people. Washington, D.C.: American Association on Mental Deficiency, 1981. Chess, S. Emotional problems in mentally retarded children. In F. J. Menalascino (Ed.), Psychiatric approaches to mental retardation. New York: Basic Books, 1970. Clark, M. J. I. A community placement program for the mentally retarded. American Journal of Mental Deficiency, 1959, 64, 548-555. Cohen, J. Statisticalpower analysis for the behavioral sciences. New York: Academic Press, 1969. Eagle, E. Prognosis and outcome of community placement of institutionalized retardates. American Journal of Mental Deficiency, 1967, 72, 232-243. Eyman, R. K., & Call, T. Maladaptive behavior and community placement of mentally retarded persons. American Journal of Mental Deficiency, 1977, 82, 137-144. Heal, L. W., Novak, A. R., Sigelman, C. K., & Switsky, H. N. Characteristics of community residential facilities. In A. R. Novak & L. W. Heal (Eds.), Integration of developmentally disabled individuals into the community. Baltimore: Paul H. Brooks, 1980, 45-57. Hill, B. K., & Bruninks, R. H. Physical and behavioral characteristics and maladaptive behavior of mentally retarded people in residential facilities. Minneapolis, MN: University of Minnesota, Department of Psychoeducational Studies, 1981. Hull, J. T., & Thompson, J. C. Predicting adaptive functioning of mentally retarded persons in community settings. American Journal of Mental Deficiency, 1980, 85, 253-261. Keppel, G. Design and analysis: A researcher's handbook. Englewood Cliffs: Prentice-Hall, 1973. Landesman-Dwyer, S., Schuckit, J. J., Keller, L. S., & Brown, T. R. A prospective study of client needs relative to community placement. In P. Mittler (Ed.), Research to practice in mental retardation: Care and intervention (Vol. I). Baltimore: University Park Press, 1977. Lemkau, P., Tietze, C., & Cooper, M. Mental hygiene problems in an urban district. Mental Hygiene, 1942, 26, 275-288. Menalascino, F. J. Emotional disturbance and mental retardation. American Journal of Mental Deficiency, 1965, 70, 248-256. Menalascino, F. J. The facade of mental retardation. American Journal of Psychiatry, 1966, 122, 1227-1235. Mulick, J. A., & Schroeder, S. R. Research relating to management of anti-social behavior in mentally retarded persons. Psychological Record, 1980, 30, 397-417. Nihira, L., & Nihira, K. Jeopardy in community placement. American Journal of Mental Deficiency, 1975, 79, 538-544. Phillips, I., & Williams, N. Psychopathology and mental retardation: A study of 100 mentally retarded children. I. Psychopathology. American Journal of Psychiatry, 1975, 132, 1265-1271. Rutter, M., Tizard, J., & Whitmore, K. Education, health and behavior. New York: Wiley, 1970. Schroeder, S. R., Mulick, J. A., & Schroeder, C. S. Management of severe behavior problems of the retarded. In R. R. Ellis (Ed.), Handbook of Mental Deficiency: Psychological theory and research (2nd ed.). Hillsdale, NJ: Lawrence Edbaum, 1979.
Behavior and Psychiatric Impairment
139
Sutter, P., Mayeda, T., Call, T., Yanagi, G., & Yee, S. Comparison of successful and unsuccessful community-placed mentally retarded persons. American Journal of Mental Deficiency, 1980, 85, 262-267. Szymanski, L. S. Psychiatric diagnostic evaluation of mentally retarded individuals. Journal of the American Academy of Child Psychiatry, 1977, 16, 67-87. Taylor, J, R. A comparison of the adaptive behavior of retarded individuals successfully and unsuccessfully placed in group living homes. Education and Training of the Mentally Retarded, 1976, 11, 56-64. Vogel, W., Kun, K. J., & Mesborer, E. Determinants of institutional release and prognosis in mental retardates. Journal of Abnormal Psychology, 1969, 74, 685-692. Webster, T. G. Unique aspects of emotional development in mentally retarded children, In F. J. Menalascino (Ed.), Psychiatric approaches to mental retardation. New York: Basic Books, 1970. Windle, C. D., Stewart, E., & Brown, S. J. Reasons for community failure of released patients. American Journal of Mental Deficiency, 1961, 66, 213-217. Wolfensberger, W. Twenty predictions about the future of residential services in mental retardation. Mental Retardation, 1969, 7, 51-54.