The relationship between cognitive development and conduct problems in young children with autism spectrum disorder

Research in Autism Spectrum Disorders 8 (2014) 1287–1294

Contents lists available at ScienceDirect

Research in Autism Spectrum Disorders Journal homepage: http://ees.elsevier.com/RASD/default.asp

The relationship between cognitive development and conduct problems in young children with autism spectrum disorder Paige E. Cervantes *, Johnny L. Matson, Hilary L. Adams, Matthew J. Konst Louisiana State University, United States

A R T I C L E I N F O

A B S T R A C T

Article history: Received 26 April 2014 Received in revised form 19 June 2014 Accepted 27 June 2014

Individuals with ASD often demonstrate elevated rates of challenging behaviors, such as tantrums, aggression, and property destruction. The current study examined the relationship between cognitive abilities and conduct problem behaviors in 263 children aged 18 to 39 months. Cognitive development was measured utilizing the cognitive developmental quotient (DQ) on the Battelle Developmental Inventory, Second Edition (BDI2). Participants were separated into two groups: (1) low cognitive DQ group (cognitive DQ less than or equal to 70), and (2) typical cognitive DQ group (cognitive DQ greater than 70). Conduct problems were assessed using the Tantrum/Conduct Behavior subscale of the Baby and Infant Screen for Children with aUtIsm Traits, Part 2 (BISCUIT-Part 2). Higher rates of overall conduct problem behaviors were observed in young children with ASD and typical cognitive development relative to children with low cognitive development. Comparisons of specific conduct behaviors indicated cognitive ability may be associated with particular presentations of conduct problems. Implications are discussed. ß 2014 Elsevier Ltd. All rights reserved.

Keywords: ASD Conduct Tantrums BISCUIT BDI-2 Cognitive

1. Introduction Autism Spectrum Disorder (ASD) is characterized by social and communication deficits and the presence of repetitive behaviors and restricted interests (Matson, 2007; Matson, Carlisle, & Bamburg, 1998; Matson & Dempsey, 2008; Matson, Gonza´lez, & Wilkins, 2008; Volkmar, Lord, Bailey, Schultz, & Klin, 2004). Additionally, many common comorbid conditions such as psychopathology, feeding problems, and other adaptive skill deficits accompany this condition (Matson, Dempsey, & Fodstad, 2009; Matson & Kuhn, 2001; Matson, Rivet, Fodstad, Dempsey, & Boisjoli, 2009; Matson et al., 1999; Matson & Smiroldo, 1997; Paclawskyj, Matson, Bamburg, & Baglio, 1997) One of the most common and concerning comorbid problems exhibited by individuals with ASD are challenging behaviors (CB; Jang, Dixon, Tarbox, & Granpeesheh, 2011; Matson, Mahan, Hess, Fodstad, & Neal, 2010; Matson, Wilkins, & Macken, 2008). CB typically displayed by this population include selfinjurious behavior (SIB), stereotypies, and externalizing behaviors like temper outbursts, aggression toward others, and destruction of property (Horner, Carr, Strain, Todd, & Reed, 2002; Matson, Mahan, Hess, & Fodstad, 2010; Matson & Rivet, 2008; McTiernan, Leader, Healy, & Mannion, 2011; Symons, Sperry, Dropik, & Bodfish, 2005). Treatment technologies are available, but identifying the problem and understanding its nature is critical (Matson & Boisjoli, 2007; Matson et al., 2005;

* Corresponding author at: Department of Psychology Louisiana State University Baton Rouge, LA 70803, United States. Tel.: +1 225 578 1494. E-mail address: [email protected] (P.E. Cervantes). http://dx.doi.org/10.1016/j.rasd.2014.06.015 1750-9467/ß 2014 Elsevier Ltd. All rights reserved.

1288

P.E. Cervantes et al. / Research in Autism Spectrum Disorders 8 (2014) 1287–1294

Matson & Wilkins, 2008; Singh, Matson, Cooper, Dixon, & Sturmey, 2005). This is made even more important since psychotropic medications are often prescribed and can result in serious side effects (Advokat, Mayville, & Matson, 2000; Mahan et al., 2010; Matson, Rivet, & Fodstad, 2008a; Matson, Rivet, & Fodstad, 2008b). Research on CB in ASD is beginning to emerge but little is known to date about the characteristics of these behaviors in very young children (Fodstad, Rojahn, & Matson, 2012). Toddlers with ASD have been found to engage in more and more severe CB than at-risk peers without ASD. Further, researchers have demonstrated that severity of aggressive and destructive behaviors in young children with ASD increases with age (Fodstad et al., 2012). In a study by Sipes, Matson, Horovitz, and Shoemaker (2011) using the same measure as the present study (i.e., BISCUIT-Part 2), the authors found that tantrum/ conduct symptoms were more prevalent among individuals with ASD than their atypically developing counterparts. The focus of the present study was on tantrum (i.e., temper outburst) and conduct behavior. The Tantrum/Conduct Behavior subscale on the measure utilized, the Baby and Infant Screen for Children with aUtIsm Traits, Part 2 (BISCUIT-Part 2; Matson, Boisjoli, & Wilkins, 2007), includes items related to over-reactivity (e.g., easily becomes upset, easily becomes angry, irritable mood), temper outbursts, property destruction, intrusiveness (e.g., interrupts, intrudes upon the activities of others), and other related CB. Many individuals with ASD exhibit the aforementioned examples of CB, which are symptoms that characterize two disorders that frequently co-occur with ASD: oppositional defiant disorder (ODD) and conduct disorder (CD). Rates of ASD and these disorders have been estimated as high as 37.2% for ODD and 9.6% for CD (de Bruin, Ferdinand, Meester, de Nijs & Verheij, 2007; Simonoff, Pickles, Charman, Chandler, & Baird, 2008). Additionally, individuals with ASD who fail to meet diagnostic criteria for ODD may still demonstrate behaviors consistent with the disorder (Gadow, DeVincent, & Drabick, 2008). For instance, Mayes and Calhoun (2011) found that the Checklist for Autism Spectrum Disorder (CASD; Mayes & Calhoun, 1999; Mayes et al., 2009) item ‘‘overreactivity, meltdowns, and/or aggression’’ was endorsed in 89– 92% of their participants with ASD. Further, Mayes et al. (2012) found that children with ASD had significantly higher endorsement of explosive, oppositional, and aggressive scores than their counterparts with attention-deficit/ hyperactivity disorder, inattentive type (ADHD-I), anxiety, brain injury, and typical development. The study of CB among this population is important because researchers have found that CB are correlated with disruption of educational opportunities (Machalicek, O’Reilly, Beretvas, Sigafoos, & Lancioni, 2007) and therapeutic intervention (Stigler & McDougle, 2008), reduced opportunity for normal activities (Matson & Nebel-Schwalm, 2007), greater parental stress (Herring, Gray, Taffe, Tonge, Sweeney, & Einfeld, 2006; Lecavalier, Leone, & Wiltz, 2006), and other negative outcomes. As such, factors that may influence the development, frequency, and/or severity of CB among individuals with ASD are crucial to investigate. One such variable worth examining is cognitive development, as differences in ASD severity have been found between individuals with high functioning ASD (HFA) and low functioning ASD (LFA), distinctions made based upon particular IQ or developmental quotient (DQ) cut-offs (Matson, Mahan, Hess, & Fodstad, 2010; Szatmari, White, & Merikangas, 2007). In particular, researchers have overwhelmingly found an inverse relationship between ASD severity and cognitive development (Matson & Shoemaker, 2009). That is, as IQ decreases, ASD symptom severity increases. Mayes and Calhoun (2011), for example, found that IQ was more significantly related to ASD symptom severity than any other factor, including age, examined in their analysis. Similarly, levels of intellectual disability can also affect levels of psychopathology and CB (Matson, Smiroldo, Hamilton, & Baglio, 1997). Based on this inverse relationship, one might expect a similar pattern between severity of related problems, such as CB, and IQ. At present, research on this topic is inconclusive. There is some evidence for different behavior profiles among individuals with ASD of varying cognitive development. For instance, Estes, Dawson, Sterling, and Munson (2007) found higher levels of hyperactivity, irritability, and attention problems among their lower functioning group. Further, Adler and colleagues (2014) found that comorbid ID was a risk factor for developing drug-refractory aggression, SIB, and severe tantrums among individuals with ASD. However, other research suggests few to no differences between groups based on IQ. Mayes and Calhoun (2011) found similar symptom profiles between HFA and LFA groups, including similar endorsement of the CASD item ‘‘overreactivity, meltdowns, and/or aggression’’ (Mayes & Calhoun, 2011). Relatedly, Mayes et al. (2012) found that behavior problem scores on the Pediatric Behavior Scale (PBS; Lindgren & Koeppl, 1987), of which these authors included the explosive items (explosive, irritable or angry, over-reactive, temper outbursts, and moody), oppositional items (defiant, argues, uncooperative, and disobedient), and aggression items (mean, threatens, fights, physically aggressive, destructive, lies, steals, and SIB), did not differ between their HFA and LFA groups. Further research is needed on the relationship between this subset of CB and cognitive development among individuals with ASD, including among different age ranges. As noted previously, little is known about the characteristics of CB in very young children with ASD. The study of this topic is very important because of the emphasis on early intervention (Matson & LoVullo, 2009). The authors of the present study aimed to further this area of research by investigating whether cognitive development was related to differences in a particular subtype of CB, specifically tantrum behavior and/or conduct problems, among infants and toddlers with ASD. Based on existent research demonstrating an exacerbation of ASD and comorbid symptomology with greater intellectual deficits (Matson, Hamilton, et al., 1997; Matson & Shoemaker, 2009; Matson, Smiroldo, et al., 1997), it is hypothesized that young children with ASD and greater cognitive impairment will evince greater CB.

P.E. Cervantes et al. / Research in Autism Spectrum Disorders 8 (2014) 1287–1294

1289

2. Method 2.1. Participants Two hundred sixty-three infants and toddlers with ASD aged 18 to 39 months old (M = 26.66, SD = 4.63) were included in the study. The sample was made up of 75.67% males and 24.33% females. In terms of ethnicity, 44.87% of the sample was African-American (n = 118), 46.01% were Caucasian (n = 121), and 9.13% were other or unspecified ethnicities (n = 24). Participants were recruited through EarlySteps, Louisiana’s early intervention program under the Individuals with Disabilities Education Act, Part C. EarlySteps offers services to infants and toddlers up to 3 years of age. Diagnoses were made by a licensed clinical psychologist according to the ASD criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), clinical judgment, as well as results from the Battelle Developmental Inventory, Second Edition (BDI-2; Newborg, 2005) and the Modified Checklist for Autism in Toddlers (M-CHAT; Robins, Fein, Barton, & Green, 2001). It is noted that the DSM-5 is controversial and rates of persons with ASD may vary markedly from Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) and the International Classification of Diseases, Tenth Revision (ICD-10; Worley & Matson, 2012). For purposes of the current analysis, participants were separated into two groups: a typical cognitive DQ group (n = 155) and a low cognitive DQ group (n = 108). Cognitive DQ scores from the BDI-2 were used as a measure of cognitive ability. Given the instability of measures of intellectual ability (i.e., IQ) in young children, examining skills in relation to developmental milestones may be more accurate and appropriate for informing intervention (Matson, Mahan, Hess, & Fodstad, 2010). Additionally, correlations between BDI-2 Cognitive DQ scores and Wechsler Preschool and Primary Scale of Intelligence (WPPSI) full scale IQ scores in young children are strong (r = .75; Newborg, 2005). Participants were placed in the typical cognitive DQ group if their cognitive DQ score on the BDI-2 was greater than 70. Children with cognitive DQ scores less than or equal to 70 were categorized into the low cognitive DQ group. Demographic information is displayed in Table 1. 2.2. Measures 2.2.1. Baby and Infant Screen for Children with aUtIsm Traits – Part 1 (BISCUIT-Part 1) The BISCUIT-Part 1 is one component of a three-part, informant-based ASD assessment designed for use with infants and toddlers between the ages of 17 and 37 months old. The BISCUIT-Part 1 was designed to assess for core ASD symptoms (e.g., eye contact, restricted interests and repetitive behaviors, nonverbal communication) and contains a total of 62 items (Matson, Boisjoli, Hess, & Wilkins, 2010; Matson, Wilkins, et al., 2009). Parents or caretakers rate their child based upon a 3-point scale for each item. A rating of 0 indicates ‘‘not a problem or impairment; not at all,’’ 1 indicates ‘‘mild problem or impairment,’’ and 2 indicates ‘‘severe problem or impairment’’ (Matson et al., 2007). Item responses are summed to a total score indicating the level of impairment observed: no autism/atypical development (a cumulative score less than 17), possible ASD (18–34), or probable ASD (greater than or equal to 35). The BISCUIT-Part 1 was utilized as a measure for autism symptom severity in the current study. 2.2.2. Baby and Infant Screen for Children with aUtIsm Traits – Part 2 (BISCUIT-Part 2) The BISCUIT Part-2 is the second component of the BISCUIT battery and is a measure of comorbid psychopathology. The BISCUIT-Part 2 contains a total of 65 items to assess for symptoms related to common co-occurring disorders (e.g., ADHD, feeding/eating problems, specific phobia; Laud, Girolami, Boscoe, & Gulotta, 2009; Ledford & Gast, 2006; Matson & NebelSchwalm, 2007; Sinzig, Walter, & Doepfner, 2009). Informant responses are centered upon the degree to which each item has been a recent problem and rated on a 3-point Likert scale ranging from 0 (‘‘not a problem’’) to 2 (‘‘severe problem;’’ Matson et al., 2007). A total score for each subscale is then calculated and reflects the overall impairment observed (Matson, Boisjoli, Hess, & Wilkins, 2011). Factor analytic research identified a five-factor solution for the BISCUIT-Part 2 (Matson et al., 2011). The five separate subscales include Inattention/Impulsivity, Anxiety/Repetitive Behavior, Eating/Sleep Problems, Avoidance Behavior, and Tantrum/Conduct Behavior. Researchers have reported that the BISCUIT-Part 2 demonstrates excellent internal reliability (a = 0.96; LoVullo & Matson, 2012; Matson, Wilkins, et al., 2009). The current study utilized the Tantrum/Conduct Behavior subscale of the BISCUIT-Part 2 as an objective measure of conduct problems (Matson et al., 2011).

Table 1 Demographic information. Group

Typical cognitive DQ (n = 155) Low cognitive DQ (n = 108)

Mean age (in months)

26.75 26.60

Gender (%)

Ethnicity (%)

Male

Female

African American

Caucasian

Other/unspecified

78.71% 71.30%

21.29% 28.70%

45.81% 43.52%

47.74% 43.52%

6.45% 12.96%

1290

P.E. Cervantes et al. / Research in Autism Spectrum Disorders 8 (2014) 1287–1294

2.2.3. Battelle Developmental Inventory, Second Edition (BDI-2) The BDI-2 is designed to assess for delay across five broad domains of childhood development (i.e., Personal/Social, Adaptive, Motor, Communication, and Cognitive). The measure was intended for use with toddlers and children from birth to 7 years 11 months of age. The BDI-2 contains 450 items that are scored according to informant response as well as direct observation. Items are scored on a 3-point scale based upon the presence or absence of ability. A score of 0 indicates ‘‘no ability in the skill;’’ a score of 1 indicates ‘‘emerging ability;’’ and a score of 2 indicates ‘‘ability at the skill.’’ A DQ is calculated for overall ability and for each of the five domains. Test-retest reliability for the BDI-2 was estimated greater than 0.80 for each individual domain and the total computed score (Newborg, 2005). Further, the criterion and content validity of the BDI2 has been demonstrated in multiple populations (e.g., language delays, motor delays, premature birth, speech delay, ASD, and developmental delays). The Cognitive domain was used in the current study and was designed to measure ‘‘intellectual’’ and ‘‘mental’’ abilities. The Cognitive domain consists of Attention and Memory, Reasoning and Academic Skills, and Perception and Concepts subdomains assessing visual and auditory ability to attend to external stimuli, critical thinking ability, and active sensorimotor interactions with the environment (Newborg, 2005). 2.3. Procedure All parents or caregivers provided informed consent prior to their inclusion in the study. Coinciding with participation in EarlySteps, parents or caregivers were administered a battery of assessments and diagnostic measures (e.g., the BISCUIT, the BDI-2). Interviewers held a minimum of a bachelor’s degree and received training in assessment administration and scoring. The Louisiana State University Institutional Review Board as well as Louisiana’s Office for Citizens with Developmental Disabilities approved the study prior to the collection of data. 2.4. Statistical analyses A priori analyses were conducted to examine possible differences among groups relating to age, ethnicity, gender, and autism symptom severity. Chi square tests indicated no significant differences for gender [X2 (1) = 1.90, p = 0.17] or ethnicity [X2 (2) = 3.29, p = 0.19]. An analysis of variance (ANOVA) was used to determine differences in age and autism symptom severity between groups. No significant differences in age were found, F(1, 261) = 0.70, p = 0.79. However, significant differences in autism symptom severity, as measured by the BISCUIT-Part 1, were observed between groups, F(1, 261) = 20.00, p < 0.001. The low cognitive DQ group (M = 60.83, SD = 20.85) had significantly higher scores on autism severity than the typical cognitive DQ group (M = 49.94, SD = 18.38). Thus, autism symptom severity was added as a covariate in subsequent analyses. An analysis of covariance (ANCOVA) was conducted with cognitive DQ group as the independent variable (IV). The overall conduct problem behavior, calculated as total score on the Tantrum/Conduct domain of the BISCUIT-Part 2, was the dependent variable (DV). Subsequently, a multivariate analysis of covariance (MANCOVA) was conducted to compare the two groups on specific conduct behavior items from the Tantrum/Conduct domain of the BISCUIT Part-2. Follow-up ANCOVAs were then utilized to examine individual item differences between groups. A Bonferonni correction was applied; p had to be less than .0026 to reach significance (i.e., p of 0.05 divided by a total of 19 items analyzed). 3. Results The initial ANCOVA indicated significant differences in overall rate of conduct problem behaviors between groups, F(1, 260) = 19.47, p < 0.001, partial h2 = 0.07. Children with ASD and a typical cognitive DQ on the BDI-2 (M = 11.54, SD = 8.16) displayed significantly more conduct problem behaviors than children with ASD and a low cognitive DQ (M = 9.43, SD = 7.10). Results for the total conduct problem comparison are presented in Table 2. A MANCOVA was then conducted to identify particular conduct problems related to cognitive skills in infants and toddlers with ASD. The MANCOVA yielded significant differences in behaviors among groups, F(19, 242) = 2.30, p = 0.002, partial h2 = 0.15. Follow-up ANCOVAs yielded significant differences among groups on six of the 19 behaviors: ‘‘easily becomes upset,’’ F(1, 261) = 14.32, p < 0.001, partial h2 = 0.05, ‘‘crying,’’ F(1,261) = 11.20, p = 0.001, partial h2 = 0.04, ‘‘destroys others’ property,’’ F(1, 261) = 11.80, p = 0.001, partial h2 = 0.04, ‘‘tantrums,’’ F(1, 261) = 15.99, p < 0.001, partial h2 = 0.06, ‘‘initiates fights,’’ F(1, 261) = 12.50, p < 0.001, partial h2 = 0.05, and ‘‘talks excessively,’’ F(1, 261) = 13.50, p < 0.001, partial Table 2 Comparison of total conduct problems. Conduct problems and level of cognitive DQ

M

SD

p-Value of IV

p-Value of covariate

Total conduct problems Typical Low

– 11.54 9.53

– 8.16 7.10

0.000 – –

0.000 – –

Note: M, mean; SD, standard deviation.

P.E. Cervantes et al. / Research in Autism Spectrum Disorders 8 (2014) 1287–1294

1291

h2 = 0.05. Despite a large effect size found for the overall MANCOVA, the effect sizes yielded from the follow-up ANCOVAs were small to medium. Infants and toddlers with ASD with a typical cognitive DQ (M = 1.36, SD = 0.82) evinced significantly higher ratings on ‘‘easily becomes upset’’ compared to children with ASD with a low cognitive DQ (M = 1.10, SD = 0.82). The typical cognitive DQ group was also found to cry significantly more (M = 0.80, SD = 0.85) and engage in more property destruction (M = 0.70, SD = .87) than the low cognitive DQ group (M = 0.60, SD = 0.82; M = 0.44, SD = 0.70, respectively). Children with ASD and a typical cognitive DQ evinced significantly more tantrum behavior (M = 1.15, SD = 0.88), initiated more fights (M = 0.45, SD = 0.76), and had higher rates of excessive talking (M = 0.73, SD = 0.77) compared to children with ASD and a low cognitive DQ (M = 0.90, SD = 0.85; M = 0.17, SD = 0.46; M = 0.52, SD = 0.69, respectively). The covariate (i.e., autism symptom severity) was significantly related to 14 of the 19 behaviors regardless of cognitive DQ score. Children with more severe ASD symptoms were more likely to be reported by parents as engaging in more problematic tantrum/conduct behaviors including: ‘‘easily becomes upset,’’ ‘‘interrupts the activities of others,’’ ‘‘crying,’’ ‘‘destroys others’ property,’’ ‘‘intrudes upon the activities of others,’’ ‘‘spiteful, vindictive, revengeful, or wanting to get back at others,’’ ‘‘damages property,’’ ‘‘deliberately annoys others,’’ ‘‘physically cruel to people or animals,’’ ‘‘tantrums,’’ ‘‘bullies, threatens, or intimidates others,’’ ‘‘irritable mood,’’ ‘‘waits for his/her turn,’’ and ‘‘talks excessively,’’ F(1, 261) = 22.17, 34.80, 29.13, 11.69, 15.20, 15.00, 41.15, 11.07, 33.23, 35.02, 22.25, 18.91, 39.90, and 25.89 respectively, all p < .0026. Results from item comparisons are presented in Table 3. 4. Discussion CB are common among persons with ASD across the lifespan (Matson, Hamilton, et al., 1997; Matson, Kiely & Bamburg, 1997; Matson & Rivet, 2008). More research on the topic is warranted, especially among young children. Results indicated that infants and toddlers with ASD demonstrated varying levels of elevated conduct problems, regardless of cognitive development. In accordance with previous research (Jang et al., 2011; Matson, Wilkins, et al., 2008), ASD severity was strongly associated with CB evinced by the participants. Regardless of cognitive ability, young children with more severe ASD symptoms were reported to engage in higher rates of a majority of the conduct behaviors explored. Cognitive DQ was found to have a small but significant effect on the conduct behaviors of infants and toddlers with ASD. However, in contrast with previous research (Estes et al., 2007; Mayes & Calhoun, 2011; Mayes et al., 2012), children with ASD and typical cognitive skills were found to engage in significantly greater rates of overall conduct problem behaviors relative to children with ASD and low cognitive development. While autism symptom severity was related to a majority of the conduct problem behaviors evaluated, cognitive development appeared to be most associated with over-reactivity and tantrum-related behaviors. Items such as ‘‘easily becomes upset,’’ ‘‘crying,’’ and ‘‘tantrums’’ differentiated children with ASD and typical cognitive DQ from children with ASD and low cognitive DQ. Further, children with ASD and typical cognitive development were found to engage in more over-reactivity and tantrum-related problem behaviors compared to those with low cognitive skills. In addition, a few aggression-related symptoms delineated the typical cognitive DQ group from the low cognitive DQ group. Higher endorsements of ‘‘initiates fights’’ and ‘‘damages others’ property’’ were found for infants and toddlers with ASD and typical cognitive skills compared to children with ASD and low cognitive ability. Therefore, children with typical cognitive development and ASD may engage in more aggression at an early age relative to children with low cognitive development and ASD. Certain aggressive behaviors, such as initiating fights and damaging property, may be of ‘‘higher order’’ and require a greater deal of motor control and adaptive skills. Additionally, researchers have suggested aggressive behavior may signify greater social awareness and competence in children when used to access wants (Vaughn, Vollenweider, Bost, Azria-Evans, & Snider, 2003). Rates of several other aggressive behaviors, however, were consistent across groups (e.g., ‘‘spiteful, vindictive, revengeful, or wanting to get back at others,’’ ‘‘bullies, threatens, or intimidates others,’’ ‘‘physically cruel to people or animals’’). Thus, the association between cognitive development and aggression in very young children with ASD requires further research. Finally, infants and toddlers with ASD and typical cognitive skills were found to engage in higher rates of excessive talking compared to those with low cognitive development. This may be attributable to differences in language ability and stage of language development. That is, children with low cognitive development may experience more impairment in language development, and may sometimes not verbalize at all or continue to have significant delays in spoken language. No differences were observed across cognitive groups for the disruptive- and impulse-related behaviors evaluated (e.g., ‘‘interrupts the activities of others,’’ ‘‘intrudes upon the activities of others,’’ ‘‘deliberately annoys others,’’ ‘‘waits for his/her turn’’). Taken together, the results further demonstrate the heterogeneous nature of ASD. In addition to vast differences in autism symptoms and severity, the presentation and expression of associated symptoms with ASD, such as conduct problems, range widely across individuals affected. Because this heterogeneity exists, comprehensive diagnostic assessments are of paramount importance. Evaluations should include not only measures of the range and severity of autism symptoms, but of symptoms congruent with common comorbid psychiatric problems as well (Matson et al., 2011). Although diagnosing mental health conditions like conduct disorders in infants and toddlers is unlikely, recognizing and flagging symptoms consistent with these common comorbidities would serve possible preventative benefits and aid in the effectiveness of early intervention programs (Matson, 2007; Matson et al., 2011).

1292

P.E. Cervantes et al. / Research in Autism Spectrum Disorders 8 (2014) 1287–1294

Table 3 Item comparison between groups. BISCUIT-Part 2 item and level of cognitive DQ

M

SD

p-Value of IV

p-Value of covariate

Easily becomes upset Typical Low Interrupts the activities of others Typical Low Crying Typical Low Destroys others’ property Typical Low Intrudes upon the activities of others Typical Low Spiteful, vindictive, revengeful, or wanting to get back at others Typical Low Damages property Typical Low Loses belongings Typical Low Tearful or weepy Typical Low Deliberately annoys others Typical Low Easily becomes angry Typical Low Physically cruel to people or animals Typical Low Tantrums Typical Low Bullies, threatens, or intimidates others Typical Low Irritable mood Typical Low Noisy while playing Typical Low Waits for his/her turn Typical Low Initiates fights Typical Low Talks excessively Typical Low

– 1.36 1.10 – 0.72 0.61 – 0.80 0.60 – 0.70 0.44 – 0.63 0.49 – 0.67 0.52 – 0.61 0.51 – 0.61 0.39 – 0.14 0.10 – 0.18 0.16 – 0.15 0.44 – 0.52 0.46 – 1.15 0.90 – 0.72 0.65 – 0.35 0.33 – 0.11 0.07 – 0.94 1.06 – 0.45 0.17 – 0.73 0.52

– 0.82 0.82 – 0.81 0.78 – 0.86 0.82 – 0.87 0.70 – 0.81 0.72 – 0.76 0.75 – 0.83 0.78 – 0.83 0.72 – 0.47 0.41 – 0.46 0.46 – 0.44 0.78 – 0.76 0.75 – 0.88 0.85 – 0.83 0.77 – 0.69 0.63 – 0.42 0.33 – 0.72 0.86 – 0.77 0.46 – 0.76 0.69

0.000 – – 0.009 – – 0.001 – – 0.001 – – 0.014 – – 0.009 – – 0.007 – – 0.004 – – 0.220 – – 0.201 – – 0.003 – – 0.030 – – 0.000 – – 0.046 – – 0.181 – – 0.320 – – 0.753 – – 0.000 – – 0.000 – –

0.000 – – 0.000 – – 0.000 – – 0.001 – – 0.000 – – 0.000 – – 0.000 – – 0.003 – – 0.017 – – 0.001 – – 0.014 – – 0.000 – – 0.000 – – 0.000 – – 0.000 – – 0.288 – – 0.000 – – 0.423 – – 0.000 – –

Note: Significance was determined by p < 0.0026.

Based on the results of the current study, level of cognitive development appears to be associated with specific presentations of conduct problems exhibited by infants and toddlers with ASD. However, due to small effect sizes, further research on this topic is warranted. Because symptom expression often fluctuates or becomes more pronounced across the course of development (Matson & Cervantes, 2014), the behavior profiles of older individuals with ASD and varying levels of cognitive skills may differ. As a result, further research on a wide range of age groups is necessary. Additionally, research targeting the evaluation of risk and protective factors in children with ASD associated with elevated conduct problems, and comorbid psychopathology in general, may improve intervention strategies. Better identification of at-risk infants and

P.E. Cervantes et al. / Research in Autism Spectrum Disorders 8 (2014) 1287–1294

1293

toddlers would allow parents and professionals to create individualized treatment plans to promote healthy development and work to mitigate future conduct problems (Matson et al., 2011).

References Adler, B. A., Wink, L. K., Early, M., Shaffer, R., Minshawi, N., McDougle, C. J., et al. (2014). Drug-refractory aggression, self-injurious behavior and severe tantrums in autism spectrum disorders: A chart review study. Autism, 18, 1–5. Advokat, C. D., Mayville, E. A., & Matson, J. L. (2000). Side effect profiles of atypical antipsychotics, typical antipsychotics or no psychotic medications in persons with mental retardation. Research in Developmental Disabilities, 21, 75–84. de Bruin, E. I., Ferdinand, R. F., Meester, S., de Nijs, P. F., & Verheij, F. (2007). High rates of psychiatric co-morbidity in PDD-NOS. Journal of Autism and Developmental Disorders, 37, 877–886. Estes, A. M., Dawson, G., Sterling, L., & Munson, J. (2007). Level of intellectual functioning predicts patterns of associated symptoms in school-age children with autism spectrum disorder. American Journal on Mental Retardation, 112, 439–449. Fodstad, J., Rojahn, J., & Matson, J. L. (2012). The emergence of challenging behaviors in at-risk toddlers with and without autism spectrum disorder: A crosssectional study. Journal of Developmental and Physical Disabilities, 24(3), 217–234. Gadow, K. D., DeVincent, C. J., & Drabick, D. A. (2008). Oppositional defiant disorder as a clinical phenotype in children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 38, 1302–1310. Herring, S., Gray, K., Taffe, J., Tonge, B., Sweeney, D., & Einfeld, S. (2006). Behaviour and emotional problems in toddlers with pervasive developmental disorders and developmental delay: Associations with parental mental health and family functioning. Journal of Intellectual Disability Research, 50, 874–882. Horner, R. H., Carr, E. G., Strain, P. S., Todd, A. W., & Reed, H. K. (2002). Problem behavior interventions for young children with autism: A research synthesis. Journal of Autism and Developmental Disorders, 32, 423–446. Jang, J., Dixon, D. R., Tarbox, J., & Granpeesheh, D. (2011). Symptom severity and challenging behavior in children with ASD. Research in Autism Spectrum Disorders, 5, 1028–1032. Laud, R. B., Girolami, P. A., Boscoe, J. H., & Gulotta, C. S. (2009). Treatment outcomes for severe feeding problems in children with autism spectrum disorder. Behavior Modification, 33(5), 520–536. Lecavalier, L., Leone, S., & Wiltz, J. (2006). The impact of behaviour problems on caregiver stress in young people with autism spectrum disorders. Journal of Intellectual Disability Research, 50, 172–183. Ledford, J. R., & Gast, D. L. (2006). Feeding problems in children with autism spectrum disorders: A review. Focus on Autism and Other Developmental Disabilities, 21(3), 153–166. Lindgren, S. D., & Koeppl, G. K. (1987). Assessing child behavior problems in a medical setting: Development of the Pediatric Behavior Scale. Advances in Behavioral Assessment of Children and Families, 3, 57–90. LoVullo, S. V., & Matson, J. L. (2012). Development of a critical item algorithm for the Baby and Infant Screen for Children with aUtIsm Traits. Research in Autism Spectrum Disorders, 6(1), 378–384. Machalicek, W., O’Reilly, M. F., Beretvas, N., Sigafoos, J., & Lancioni, G. E. (2007). A review of interventions to reduce challenging behavior in school settings for students with autism spectrum disorders. Research in Autism Spectrum Disorders, 1, 229–246. Mahan, S., Holloway, J., Bamburg, J. W., Hess, J. A., Fodstad, J. C., & Matson, J. L. (2010). An examination of psychotropic medication side effects: Does taking a greater number of psychotropic medications from different classes affect presentation of side effects in adults with ID? Research in Developmental Disabilities, 31, 1561–1569. Matson, J. L. (2007). Current status of differential diagnosis for children with autism spectrum disorders. Research in Developmental Disabilities, 28, 109–118. Matson, J. L., & Boisjoli, J. (2007). Multiple versus single maintaining factors of challenging behaviors as assessed by the QABF for adults with intellectual disability (ID). Journal of Intellectual and Developmental Disability, 32, 39–44. Matson, J. L., Boisjoli, J. A., Hess, J., & Wilkins, J. (2010). Factor structure and diagnostic fidelity of the Baby and Infant Screen for Children with aUtIsm Traits-Part 1 (BISCUIT-Part 1). Developmental Neurorehabilitation, 13, 72–79. Matson, J. L., Boisjoli, J. A., Hess, J. A., & Wilkins, J. (2011). Comorbid psychopathology factor structure on the Baby and Infant Screen for Children with aUtIsm Traits-Part 2 (BISCUIT-Part 2). Research in Autism Spectrum Disorders, 5, 426–432. Matson, J. L., Boisjoli, J., & Wilkins, J. (2007). The Baby and Infant Screen for Children with aUtIsm Traits (BISCUIT). Baton Rouge, LA: Disability Consultants, LLC. Matson, J. L., Carlisle, C. B., & Bamburg, J. W. (1998). The convergent validity of the matson evaluation of social skills in persons with severe retardation (MESSIER). Research in Developmental Disabilities, 19, 493–500. Matson, J. L., & Cervantes, P. E. (2014). Commonly studied comorbid psychopathologies among persons with autism spectrum disorder. Research in Developmental Disabilities, 35(5), 952–962. Matson, J. L., & Dempsey, T. (2008). Stereotypy in adults with autism spectrum disorders: Relationship and diagnostic fidelity. Journal of Developmental and Physical Disabilities, 20, 155–165. Matson, J. L., Dempsey, T., & Fodstad, J. C. (2009). The effect of autism spectrum disorders on adaptive independent living skills in adults with severe intellectual disability. Research in Developmental Disabilities, 30, 1203–1211. Matson, J. L., Gonza´lez, M. L., Wilkins, J., & Rivet, T. T. (2008). Reliability of the autism spectrum disorders-diagnostic for children (ASD-DC). Research in Autism Spectrum Disorders, 2, 696–706. Matson, J. L., Hamilton, M., Duncan, D., Bamburg, J., Smiroldo, B., Anderson, S., et al. (1997). Characteristics of stereotypic movement disorder and self-injurious behavior as assessed with the Diagnostic Assessment for the Severely Handicapped (DASH-II). Research in Developmental Disabilities, 18, 457–469. Matson, J. L., Kiely, S. L., & Bamburg, J. W. (1997). The effects of stereotypies on adaptive skills as assessed with the DASH-II and the Vineland Adaptive Behavior Scale. Research in Developmental Disabilities, 18, 471–476. Matson, J. L., & Kuhn, D. E. (2001). Identifying feeding problems in mentally retarded persons: Development and reliability of the Screening Tool of Feeding Problems (STEP). Research in Developmental Disabilities, 22, 165–172. Matson, J. L., & LoVullo, S. V. (2009). Trends and topics in autism spectrum disorders research. Research in Autism Spectrum Disorders, 3, 252–257. Matson, J. L., Mahan, S., Hess, J. A., & Fodstad, J. C. (2010). Effect of developmental quotient on symptoms of inattention and impulsivity among toddlers with autism spectrum disorders. Research in Developmental Disabilities, 31, 464–469. Matson, J. L., Mahan, S., Hess, J. A., Fodstad, J. C., & Neal, D. (2010). Progression of challenging behaviors in children and adolescents with autism spectrum disorders as measured by the autism spectrum disorders-problem behaviors for children (ASD-PBC). Research in Autism Spectrum Disorders, 4, 400–404. Matson, J. L., Mahan, S., & LoVullo, S. V. (2009). Parent training: A review of methods for children with developmental disabilities. Research in Developmental Disabilities, 30, 961–968. Matson, J. L., Mayville, S. B., Kuhn, D. E., Sturmey, P., Laud, R. B., & Cooper, C. (2005). The behavioral function of feeding problems as assessed by the questions about behavior function (QABF). Research in Developmental Disabilities, 26, 399–408. Matson, J. L., & Nebel-Schwalm, M. (2007). Assessing challenging behaviors in children with autism spectrum disorders: A review. Research in Developmental Disabilities, 28, 567–579. Matson, J. L., & Rivet, T. T. (2008). Characteristics of challenging behaviours in adults with autistic disorder, PDD-NOS and intellectual disability. Journal of Intellectual and Developmental Disability, 33, 323–329. Matson, J. L., Rivet, T. T., & Fodstad, J. C. (2008a). Matson evaluation of drug side-effects (MEDS) profiles in adults with intellectual disability, tardive dyskinesia and akathisia. Journal of Developmental and Physical Disabilities, 20, 283–295.

1294

P.E. Cervantes et al. / Research in Autism Spectrum Disorders 8 (2014) 1287–1294

Matson, J. L., Rivet, T. T., & Fodstad, J. C. (2008b). Psychometric properties and participant characteristics for persons with intellectual disability using the Matson Evaluation of Drug Side-effects (MEDS). Journal of Developmental and Physical Disabilities, 20, 243–255. Matson, J. L., Rivet, T. T., Fodstad, J. C., Dempsey, T., & Boisjoli, J. A. (2009). Examination of adaptive behavior differences in adults with autism spectrum disorders and intellectual disability. Research in Developmental Disabilities, 30, 1317–1325. Matson, J. L., Rush, K. S., Hamilton, M., Anderson, S. J., Bamburg, J. W., Baglio, C. S., et al. (1999). Characteristics of depression as assessed by the Diagnostic Assessment for the Severely Handicapped II (DASH-II). Research in Developmental Disabilities, 20, 305–313. Matson, J. L., & Shoemaker, M. (2009). Intellectual disability and its relationship to autism spectrum disorders. Research in Developmental Disabilities, 30, 1107– 1114. Matson, J. L., & Smiroldo, B. B. (1997). Validity of the mania subscale of the DASH-II. Research in Developmental Disabilities, 18, 221–226. Matson, J. L., Smiroldo, B. B., Hamilton, M., & Baglio, C. (1997). Do anxiety disorders exist in persons with severe and profound mental retardation? Research in Developmental Disabilities, 18, 39–44. Matson, J. L., & Wilkins, J. (2008). Antipsychotic drug use for the aggression of persons with intellectual disability. The Lancet, 371, 9–10. Matson, J. L., Wilkins, J., & Macken, J. (2008). The relationship of challenging behaviors to severity and symptoms of autism spectrum disorders. Journal of Mental Health Research in Intellectual Disabilities, 2, 29–44. Matson, J. L., Wilkins, J., Sevin, J. A., Knight, C., Boisjoli, J. A., & Sharp, B. (2009). Reliability and item content of the Baby and Infant Screen for Children with aUtIsm Traits (BISCUIT): Parts 1–3. Research in Autism Spectrum Disorders, 3, 336–344. Mayes, S. D., & Calhoun, S. L. (1999). Symptoms of autism in young children and correspondence with the DSM. Infants and Young Children, 12, 90–97. Mayes, S. D., & Calhoun, S. L. (2011). Impact of IQ, age, SES, gender, and race on autistic symptoms. Research in Autism Spectrum Disorders, 5(2), 749–757. Mayes, S. D., Calhoun, S. L., Aggarwal, R., Baker, C., Mathapati, S., Anderson, R., et al. (2012). Explosive, oppositional, and aggressive behavior in children with autism compared to other clinical disorders and typical children. Research in Autism Spectrum Disorders, 6(1), 1–10. Mayes, S. D., Calhoun, S. L., Murray, M. J., Morrow, J. D., Yurich, K. K., Mahr, F., et al. (2009). Comparison of scores on the Checklist for Autism Spectrum Disorder, Childhood Autism Rating Scale, and Gilliam Asperger’s Disorder Scale for children with low functioning autism, high functioning autism, Asperger’s disorder, ADHD, and typical development. Journal of Autism and Developmental Disorders, 39, 1682–1693. McTiernan, A., Leader, G., Healy, O., & Mannion, A. (2011). Analysis of risk factors and early predictors of challenging behavior for children with autism spectrum disorder. Research in Autism Spectrum Disorders, 5, 1215–1222. Newborg, J. (2005). Battelle developmental inventory (2nd ed.). Itasca, IL: Riverside. Paclawskyj, T. R., Matson, J. L., Bamburg, J., & Baglio, C. S. (1997). A comparison of the Diagnostic Assessment for the Severely Handicapped-II (DASH-II) and the Aberrant Behavior Checklist (ABC). Research in Developmental Disabilities, 18, 289–298. Robins, D. L., Fein, D., Barton, M. L., & Green, J. A. (2001). The modified checklist for autism in toddlers: An initial study investigating the early detection of autism and pervasive developmental disorders. Journal of Autism and Developmental Disorders, 31(2), 131–144. Simonoff, E., Pickles, A., Charman, T., Chandler, T. L., & Baird, G. (2008). Psychiatric disorders in children with autism spectrum disorders: Prevalence, comorbidity, and associated factors in a population-derived sample. Journal of the American Academy of Child and Adolescent Psychiatry, 47, 921–929. Singh, A. N., Matson, J. L., Cooper, C. L., Dixon, D., & Sturmey, P. (2005). The use of risperidone among individuals with mental retardation: Clinically supported or not? Research in Developmental Disabilities, 26, 203–218. Sinzig, J., Walter, D., & Doepfner, M. (2009). Attention deficit/hyperactivity disorder in children and adolescents with autism spectrum disorder symptom or syndrome? Journal of Attention Disorders, 13(2), 117–126. Sipes, M., Matson, J. L., Horovitz, M., & Shoemaker, M. (2011). The relationship between autism spectrum disorders and symptoms of conduct problems: The moderating effect of communication. Developmental Neurorehabilitation, 14, 54–59. Stigler, K. A., & McDougle, C. J. (2008). Pharmacotherapy of irritability in pervasive developmental disorders. Child and Adolescent Psychiatric Clinics of North America, 17, 739–752. Symons, F. J., Sperry, L. A., Dropik, P. L., & Bodfish, J. W. (2005). The early development of stereotypy and self injury: A review of research methods. Journal of Intellectual Disability Research, 49, 144–158. Szatmari, P., White, J., & Merikangas, K. R. (2007). The use of genetic epidemiology to guide classification in child and adult psychopathology. International Review of Psychiatry, 19, 483–496. Vaughn, B. E., Vollenweider, M., Bost, K. K., Azria-Evans, M. R., & Snider, J. (2003). Negative interactions and social competence for preschool children in two samples: Reconsidering the interpretation of aggressive behavior for young children. Merrill-Palmer Quarterly, 49(3), 245–278. Volkmar, F. R., Lord, C., Bailey, A., Schultz, R. T., & Klin, A. (2004). Autism and pervasive developmental disorders. Journal of Child Psychology and Psychiatry, 45(1), 135–170. Worley, J. A., & Matson, J. L. (2012). Comparing symptoms of autism spectrum disorders using the current DSM-IV-TR diagnostic criteria and the proposed DSM-V diagnostic criteria. Research in Autism Spectrum Disorders, 6, 965–970.