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Validity of the Autism Spectrum Disorder-Comorbid for Children (ASD-CC)
Research in Autism Spectrum Disorders 3 (2009) 345–357
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Research in Autism Spectrum Disorders Journal homepage: http://ees.elsevier.com/RASD/default.asp
Validity of the Autism Spectrum Disorder-Comorbid for Children (ASD-CC) Johnny L. Matson *, Santino V. LoVullo, Tessa T. Rivet, Jessica A. Boisjoli Department of Psychology, Louisiana State University, Baton Rouge, LA 70803, United States
A R T I C L E I N F O
A B S T R A C T
Keywords: ASD Autism Comorbid Assessment
A limited number of studies currently exist focusing on comorbid psychopathology of children with autism spectrum disorders (ASDs). Due to the heterogeneity of ASD symptoms, communication deficits, and impairments in intellectual functioning, assessing symptoms of psychopathology is complicated. The Autism Spectrum Disorders-Comorbidity for Children (ASD-CC) is a new measure, incorporated in an extensive assessment battery, designed to assess children with ASD for comorbid psychopathology. Reliability analyses of the ASD-CC have been conducted [Matson, J. L., & Wilkins, J. (2008). Reliability of the Autism Spectrum Disorders-Comorbidity for Children (ASD-CC). Journal of Developmental and Physical Disabilities, 20, 155–165]. The aim of this study was to identify the factor structure of the ASD-CC and evaluate construct validity of the measure by correlating the empirically derived factors with subscales of the Behavioral Assessment System for Children, Version 2 (BASC-2). Results of the analyses included a seven-factor solution. The factors were composed of items consistent with Tantrum Behavior, Repetitive Behavior, Worry/Depressed, Avoidant Behavior, Under-Eating, Over-Eating, and Conduct. Convergence between some factors of the ASD-CC and related subscales was observed as was discrimination between unrelated factors of the two measures. The ASD-CC appears to be a valid measure of comorbid psychopathology in the ASD population. ß 2008 Elsevier Ltd. All rights reserved.
* Corresponding author. E-mail address: [email protected] (J.L. Matson). 1750-9467/$ – see front matter ß 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.rasd.2008.08.002
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1. Introduction Autism Spectrum Disorders (ASDs) are a group of neurodevelopmental disorders characterized by impairments in three core domains: socialization, communication, and repetitive behaviors/instance on sameness. While each child with ASD evinces deficits in socialization, and deficits in communication and/or behavioral disturbances, heterogeneity in the presentation of symptoms is common to this population, making differential diagnosis difficult (Siklos & Kerns, 2007). To further complicate the diagnostic picture, children with ASD often display maladaptive behaviors such as physical aggression, noncompliance, and pica (Applegate, Matson, & Cherry, 1999; Dominick, Davis, Lainhart, Tager-Flusberg, & Folstein, 2007; Matson & Logan, 1997), as well as genetic disorders and other forms of psychopathology (Matson & Nebel-Schwalm, 2007b). The term comorbidity refers to the co-occurrence of more than one form of psychopathology in the same person (Matson & Bamburg, 1998; Matson & Nebel-Schwalm, 2007b; Singh, Matson, Cooper, Dixon, & Sturmey, 2005). One of the more commonly studied comorbid disorders with ASD is intellectual disability (ID). Up to 70% of children diagnosed with autism also have ID (Fombonne, 2003). For the purposes of this article, we refer to comorbidity as ASD co-occurring with another mental health disorder not including ID. Less studied disorders co-occurring with ASD include anxiety, fears, tics, depression, mania, and attention problems (Gadow & DeVincent, 2005; Gadow, DeVincent, Pomeroy, & Azizian, 2004; Ghaziuddin, Tsai, & Ghaziuddin, 1992; Goldstein & Schwebach, 2004; Matson & Love, 1990; Matson, Smiroldo, Hamilton, & Baglio, 1997; Tantum, 2000; Wozniak et al., 1997). Other disorders, such as obsessive compulsive disorder (OCD) and depression, have been reported to occur at higher rates in family members of people diagnosed with ASD than in the general population (Ghaziuddin, 2000; Hollander, King, Delaney, Smith, & Silverman, 2003). The presence of comorbid psychopathology in this population necessitates further study (Rojahn, Matson, Lott, Esbensen, & Smalls, 2001). The literature base on the co-occurrence of ASD and other forms of psychopathology is drawn from a limited number of small-scale studies. One difficulty in identifying comorbid conditions in this particular population is distinguishing symptoms of psychopathology from core features of ASD (Matson et al., 1996; Matson, Smiroldo, & Hastings, 1998; Paclawskyj, Matson, Bamburg, & Baglio, 1997). People with ASD exhibit behaviors such as restricted interests, rituals, and stereotypies that may look topographically similar to obsessions, compulsions, or tics, for example. They may also exhibit a restricted range of facial expression and have limited verbal ability complicating assessment. Another difficulty in the assessment of psychopathology in people with ASD is communication deficits characteristic of this disorder. Approximately half of all people diagnosed with an ASD never develop speech (Prizant, 1996). Of the half who do talk, the speech may be limited in functional content. Tied into the communication deficits in children with ASD is the confounding diagnosis of ID in many children. With increasing severity of ID, verbal ability decreases and self-report may not be feasible (Cherry, Matson, & Paclawskyj, 1997; Matson & Smiroldo, 1997). Clinicians are often left to rely on parent/caretaker report and/or behavioral observation to identify psychopathology in this population. Parent/caretaker rating scales are used for this purpose. Numerous scales exist to assess the core symptoms of ASD; however, very few are available to assess symptoms of psychopathology in this population. Of the available tests for assessing psychopathology in the typically developing and ID populations, many have not been researched specifically with children with ASD. Parent/teacher report measures such as the Early Childhood Inventory-4 (ECI-4) (Sprafkin, Volpe, Gadow, Nolan, & Kelly, 2002), the Child Symptom Inventory-4 (CSI4) (Gadow & Sprafkin, 1998), and the Diagnostic Interview Schedule for Children (DISC) have been used with children with ASD. However, the psychometric properties of the scales have yet to be established with this population. The Nisonger Child Behavior Rating Forms (NCBRF) (Aman, Tasse´, Rojahn, & Hammer, 1996) is an exception in that it has been evaluated with the ASD population including a factor analysis which resulted in a different structure than the original factor analysis of children with ID (Lecavalier, Aman, Hammer, Stocia, & Mathews, 2004). Because of these limitations a new measure, the Autism Spectrum Disorders-Comorbidity for Children (ASD-CC), was developed to specifically assess children diagnosed with an ASD for comorbid psychopathology. Given the requirements of disorder
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specific assessment for the ASD population and the frequency with which it occurs in the general population, such a scale seemed warranted. Initial research with the ASD-CC shows promise, however, the scale is still in the initial stages of development (Matson & Wilkins, 2008). The aim of this study was to establish the factor structure of the ASD-CC using exploratory factor analysis and evaluate the construct validity of the measure by examining intercorrelations of the empirically derived factors of the ASD-CC. 2. Method 2.1. Participants Participants were recruited throughout the United States from a variety of clinic and school settings, as well as community organizations. Recruitment was based on self or professional referral. Typically developing children and children with developmental disorders were recruited. The project was described as a study on the development of measures to assess autism spectrum disorders and cooccurring problems. IRB approval and informed consent from parents/guardians were obtained. The sample included 311 children and adolescents. One hundred and thirty-four of the participants were excluded due to failure to meet inclusion criteria of an ASD diagnosis (see below for inclusion criteria). The final sample included 177 children and adolescents between 2 and 17 years of age (M = 8.51, S.D. = 3.95). Sixty-two percent of the children were Caucasian, 8% were African American, and 3% were Hispanic, with the remainder of the sample having other or unspecified races. The majority of children were male (78%) and had some verbal skills (60%). Twelve percent of children were identified by informants as having an ID. Twenty-nine percent of the participants were prescribed one or more psychotropic medications at the time the measures were completed. In order to determine inclusion criteria and standardize ASD diagnoses across sites, a composite symptom checklist from the DSM-IV-TR (American Psychiatric Association, 2000) and International Classification of Diseases, Tenth Edition (World Health Organization, 1992) was used. Two deficits in social interaction and one in another area of functioning (e.g. communication or repetitive behaviors/ interests) were required and a diagnosis by a licensed Ph.D. level clinical psychologist for inclusion in the study. Inter-rater reliability, test–retest reliability, and internal consistency (r = .89; r = .96; a = .95, respectively) of the checklist for a subset of the sample proved excellent (Matson, Gonzalez, Wilkins, & Rivet, 2007). Five children had previous ASD diagnoses, but were excluded because they did not meet the research criteria described for this study. According to parent report, ASD diagnoses were Autistic disorder (37%), PDDNOS (18%), and Asperger’s disorder (8%), with 15% not reporting a specific ASD. Additional diagnoses included nonverbal learning disability, anxiety disorders, attention deficit/hyperactivity disorder (ADHD), bipolar disorder, depression, developmental delay, Down’s syndrome, fetal alcohol syndrome, Fragile X Syndrome, learning disorders, language disorders, sensory integration dysfunction, oppositional defiant disorder, seizure disorder, stereotypic movement disorder, tics, selective mutism, psychosis, and psychopathology (unspecified). 2.2. Test materials Parents or caregivers completed the ASD-CC and DSM-IV-TR/ICD-10 checklist independently according to the directions printed at the top of the questionnaire. Doctoral students in clinical psychology were available to help resolve any questions parents had while completing the measure. 2.3. Autism Spectrum Disorders-Comorbid for Children The ASD-CC is a 49-item, informant-based rating scale designed to assess symptoms of emotional difficulties which commonly occur with ASD. Items encompass comorbid conditions such as depression, conduct disorder, ADHD, tic disorder, OCD, specific phobia, and eating difficulties. Caregivers rate each item to the extent that it has been a recent problem as either 0 = ‘‘not a problem or impairment; not at all,’’ 1 = ‘‘mild problem or impairment,’’ 2 = ‘‘severe problem or impairment,’’ or
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X = ‘‘does not apply or don’t know.’’ The ASD-CC has been found to have moderately good inter-rater (k = .46) and test–retest reliability (k = .51) and very good internal consistency (a = .91; Matson & Dempsey, 2008). Behavior Assessment System for Children-2 (BASC-2; Reynolds & Kamphaus, 2004). The BASC-2 is a broad-band assessment of clinical and adaptive dimensions for children ages 2–21 years. The BASC-2 was chosen as a comparison in evaluating the construct validity of the ASD-CC because it provides norms and distinct clinical profiles for children with ASD and other childhood disorders. The present study utilized the BASC-2 parent-rating forms, which are comprised of three versions: preschool (ages 2–5), child (ages 6–11), and adolescent (ages 12–21). Items are rated from 1 (never) to 4 (almost always). The dimensions rated include: aggression, hyperactivity, conduct problems, anxiety, depression, somatization, attention problems, learning problems, atypicality, withdrawal, adaptability, activities of daily living, functional communication, leadership, social skills, and study skills. Authors of the BASC-2 report internal consistency as high (ranging from a = .85 to .95 for general samples and .89–.95 for clinical samples), test–retest reliability ranging from .76 to .92, and inter-rater reliability ranging from .70 to .88. In addition, concurrent validity was high with the Child Behavior Checklist (Achenbach, Rescorla, & Maruish, 2004). 3. Results and discussion First, an exploratory factor analysis using principal axis factoring for extraction and a promax rotation was computed with the items of the ASD-CC. Factor loadings are generally considered meaningful when exceeding .30 or .40 (Floyd & Widaman, 1995). A combination of methods was used to determine the number of factors extracted, including the scree plot, eigenvalues, number of items per factor, simple structure, and interpretability (Comrey, 1988; Costello & Osborne, 2005; Floyd & Widaman, 1995). Internal consistency of the ASD-CC factors and overall scale were computed. Next, Pearson correlations were computed between the ASD-CC factors. Inter-subscale correlations were also computed separately for the BASC-2 Clinical and Adaptive subscales. Finally, correlations were computed to establish convergent and discriminate validity of the ASD-CC factors with the clinical and adaptive subscales of the BASC-2 (Campbell & Fiske, 1959). It was hypothesized that the ASD-CC would show overall convergence with related ASD-CC factors and BASC-2 Clinical subscales and overall discrimination with unrelated factors of the ASD-CC and BASC-2. 3.1. Factor analysis For the initial factor analysis of the 49 items of the ASD-CC, the Kaiser–Meyer–Olkin (KMO) index of sampling adequacy was .79, and the test of sphericity was highly significant (p < .001), indicating that the data were acceptable for factor analysis. In addition, communalities ranged from .33 to .70. A seven-factor solution was selected by considering multiple criteria, as outlined above. The sevenfactor solution, also conducted using principal axis factoring with a promax rotation, accounted for 42.64% of the variance. Factor 1 (Tantrum Behavior) accounted for 18.82% of the variance, Factor 2 (Repetitive Behavior) accounted for 6.69%, Factor 3 (Worry/Depressed) accounted for 4.76%, Factor 4 (Avoidant Behavior) accounted for 4.00%, Factor 5 (Under-Eating) accounted for 3.56%, Factor 6 (Conduct) accounted for 2.69%, and Factor 7 (Over-Eating) accounted for 2.13%. Factor correlations ranged from .00 to .54. One item (Tearful or weepy) cross-loaded on Factors 1 and 3, but was rationally assigned to Factor 3 as it conceptually fit better with the Worry/Depressed factor. Ten items were removed because their factor loadings failed to meet a minimum criterion of .40. The pattern matrix for the seven-factor solution is presented in Table 1. Internal consistency was calculated for the ASD-CC factors. The exclusion of any item did not result in a substantial increase in a for any of the factors. a, scale means and standard deviations were as follows for the seven factors: Tantrum Behavior (a = .86; M = 7.41, S.D. = 4.48), Repetitive Behavior (a = .75; M = 5.06, S.D. = 3.52), Worry/Depressed (a = .74; M = 2.12, S.D. = 2.34), Avoidant Behavior (a = .77; M = 3.85, S.D. = 2.97), Under-Eating (a = .78; M = 1.01, S.D. = 1.54), Conduct (a = .74; M = 1.33, S.D. = 1.78), and Over-Eating (a = .70; M = 1.46, S.D. = 1.67).
Table 1 Factor structure of the ASD-CC Item
47 38 33 12 42 31 36 46 26 16 37 22 27 23 19 6
Tantrums Easily becomes angry Irritable mood Easily becomes upset Crying Tearful or weepy Damages property Compliance with demands Finishes assigned tasks Destroys other’s property Sudden, rapid, repetitive movements or vocalizations that are not associated with a physical disability Sudden, rapid, repetitive movement or vocalization that occurs for no apparent reason Persistent or recurring impulses that interfere with activities Checking on play objects excessively Engages in repetitive behaviors Eats things that are not meant to be eaten Engages in behaviors that impair daily routine or activities. Fidgets or squirms Experiences excessive worry or concern Feelings of worthlessness or excessive guilt Has persistent or recurring thoughts that cause distress Low energy or fatigue Loses belongings Avoids specific objects, persons, or situations causing interference with his/her normal routine Avoids specific situations, people, or events Withdraws or removes him/her self from social situations Will eat only certain foods
Factor 2 (Repetitive Behavior)
.74 .72 .72 .63 .61 .60 .51 .48 .43 .43
Factor 3 (Worry/ Depressed)
Factor 4 (Avoidant Behavior)
Factor 5 (UnderEating)
Factor 6 (Conduct)
Factor 7 (OverEating)
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35 32 44 1 5 25 21 13 29 7 4
Factor 1 (Tantrum Behavior)
.40
.68
.62 .55 .54 .50 .44 .42 .41 .67 .56 .50 .49 .48 .71 .68 .59 .54
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350
Item
3 20 14 18 28 8 9 17 49 2 11 48
Factor 1 (Tantrum Behavior) Fear of being around others in school, at home, or social situations Has trouble sleeping Has a poor appetite Eats too little Weight loss Blames others for his/her misdeeds Lies to obtain goods or favors Spiteful, vindictive, revengeful, or wants to get back at others Blurts out comments or words at inappropriate times Eats too much Weight gain Eats too quickly
Factor 2 (Repetitive Behavior)
Factor 3 (Worry/ Depressed)
Factor 4 (Avoidant Behavior)
Factor 5 (UnderEating)
Factor 6 (Conduct)
Factor 7 (OverEating)
.49 .40 .88 .81 .58 .79 .73 .67 .40 .69 .62 .48
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Table 1 (Continued )
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Table 2 Intercorrelations between ASD-CC subscales (n = 178) ASD-CC subscales
ASD-CC subscales Factor 1 (Tantrum Behavior)
Factor 1 (Tantrum Behavior) Factor 2 (Repetitive Behavior) Factor 3 (Worry/Depressed) Factor 4 (Avoidant Behavior) Factor 5 (Under-Eating) Factor 6 (Conduct) Factor 7 (Over-Eating) ASD-CC Composite
–
Factor 2 (Repetitive Behavior) .46** –
Factor 3 (Worry/ Depressed)
Factor 4 (Avoidant Behavior)
Factor 5 (UnderEating)
Factor 6 (Conduct)
Factor 7 (OverEating)
ASD-CC Composite
.29**
.42**
.02**
.48**
.35**
.82**
.11**
.30**
.05**
.24**
.24**
.66**
.31**
.15**
.52**
.29**
.58**
.18**
.30**
.18**
.62**
.10** –
.02** .24** –
.23** .65** .51** –
–
– –
**p < .01.
3.2. Intercorrelations Intercorrelations between the seven factors of the ASD-CC were calculated. Correlations between each factor and the ASD-CC Composite Score ranged from .23 (Under-Eating) to .82 (Tantrum Behavior). Inter-factor correlations ranged from .02 (Under-Eating and Over-Eating; Under-Eating and Tantrum Behavior) to .48 (Tantrum Behavior and Conduct). Intercorrelations between the BASC-2 Clinical subscales were also calculated. Correlations between each subscale and the BASC-2 Behavioral Symptoms Index (BSI) ranged from .30 (Anxiety) and .72 (Hyperactivity). Inter-subscale correlations ranged from .01 (Attention Problems and Anxiety) to .78 (Anxiety and Depression). Lastly, intercorrelations were computed between the BASC-2 Adaptive subscales. Correlations between each subscale and the BASC-2 Adaptive Skills Composite ranged from .53 (Adaptability) to .80 (Social Skills). Inter-subscale correlations ranged from .23 (Adaptability and Leadership) to .66 (Social Skills and Leadership; Social Skills and Functional Communication). Table 2 provides intercorrelations between the ASD-CC factors, Table 3 provides intercorrelations between the BASC-2 Clinical subscales, and Table 4 provides intercorrelations between the BASC-2 Adaptive subscales. 3.3. ASD-CC factor and BASC-2 Clinical subscale correlations The ASD-CC Composite Score showed strong convergence with the BASC-2 Clinical subscales (r = .66). Relationships between the ASD-CC factors and the BASC-2 BSI ranged from .13 (UnderEating) to .63 (Tantrum Behavior). The ASD-CC Tantrum Behavior factor was strongly associated with the BASC-2 BSI. The ASD-CC Over-Eating, Worry/Depressed, Conduct, and Avoidant Behavior factors showed moderate relationships with the BASC-2 BSI. The ASD-CC Repetitive Behavior factor had a weak relationship with the BASC-2 BSI, and the ASD-CC Under-Eating factor had a weak negative relationship with the BASC-2 BSI. Relationships between the BASC-2 subscales and the ASD-CC Composite Score ranged from .19 (Anxiety) to .61 (Atypicality). The BASC-2 Atypicality and Hyperactivity subscales were strongly associated with the ASD-CC Composite Score. The BASC-2 Aggression, Depression, Somatization, and Conduct Problems subscales were moderately associated with the ASD-CC Composite Score. The BASC-2 Attention Problems, Withdrawal, and Anxiety subscales had weak relationships with the ASD-CC Composite Score. Table 5 provides the correlation matrix between ASD-CC factors and BASC-2 Clinical subscales, including the ASD-CC Composite Score and the BASC-2 BSI. Intercorrelations between ASD-CC factors and BASC-2 Clinical subscales ranged from .22 (BASC-2 Anxiety and ASD-CC Repetitive Behavior) to .68 (BASC-2 Anxiety and ASD-CC Worry/Depressed). The ASD-CC Tantrum Behavior factor showed strong relationships with the BASC-2 Hyperactivity and
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BASC-2 subscales
BASC-2 Clinical subscales
Hyperactivity Aggression Conduct Anxiety Depression Somatization Atypicality Withdrawal Attention BASC-2 BSI
.67** –
Aggression
Conduct Problems .70** .60** –
Anxiety
Depression
Somatization
Atypicality
Withdrawal
Attention Problems
BASC-2 BSI
.34* .41** .38* –
.58** .63** .62** .78** –
.41** .41** .46** .49** .61** –
.37** .29* .28 .02 .26 .32* –
.03 .11 .04 .03 .18 .12 .41** –
.40** .28* .47** .01 .23 .18 .34* .17 –
.72** .70** .47** .30* .57** .46** .74** .50** .45** –
**p < .01, *p < .05. Note: Correlations involving the BASC-2 Conduct Problems subscale have n = 39 due to age limits.
J.L. Matson et al. / Research in Autism Spectrum Disorders 3 (2009) 345–357
Table 3 Intercorrelations between BASC-2 Clinical subscales (n = 52)
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Table 4 Intercorrelations between BASC-2 Adaptive subscales (n = 52) BASC-2 subscales
BASC-2 Adaptive subscales
Adaptability Social Skills Leadership Activities of Daily Living Functional Communication Adaptive Skills Composite
Adaptability
Social Skills
Leadership
Activities of Daily Living
Functional Communication
Adaptive Skills Composite
–
.38** –
.23 .66** –
.38** .59** .64** –
.26 .66** .63** .58** –
.53** .80** .66** .78** .79** –
**p < .01, *p < .05. Note: Correlations involving the BASC-2 Leadership subscale have n = 39 due to age limits.
Table 5 Intercorrelations between ASD-CC and BASC-2 Clinical subscales (n = 52) BASC-2 subscales
ASD-CC subscales Tantrum Behavior
Hyperactivity Aggression Conduct Problems Anxiety Depression Somatization Atypicality Withdrawal Attention Problems BASC-2 BSI
Repetitive Behavior
.57** .54** .34* .12 .32* .26 .49** .17 .36** .63**
.30* .12 .25 .22 .00 .24 .48** .03 .26 .29*
Worry/ Depressed
Avoidant Behavior
.32* .32* .30 .68** .66** .52** .33* .18 .07 .44**
.16 .13 .05 .12 .16 .12 .27* .32* .04 .30*
UnderEating
Conduct
.02 .03 .21 .11 .09 .14 .10 .00 .00 .13
.40** .43** .44** .48** .56** .39** .31* .01 .07 .43**
OverEating .33* .28* .46** .02 .24 .25 .42** .27 .17 .44**
ASD-CC Composite .58** .49** .44** .19 .47** .47** .61** .21 .28* .66**
**p < .01, *p < .05. Note: Correlations involving the BASC-2 Conduct Problems subscale have n = 39 due to age limits.
Aggression subscales, moderate relationships with the BASC-2 Atypicality, Attention Problems, Conduct Problems, and Depression subscales, and weak relationships with the BASC-2 Somatization, Withdrawal, and Anxiety subscales. The ASD-CC Repetitive Behavior factor was moderately associated with the BASC-2 Atypicality and Hyperactivity subscales, weakly associated with the BASC-2 Attention Problems, Hyperactivity, Conduct Problems, Somatization, and Aggression subscales, and had a weak negative association with the BASC-2 Anxiety subscale. The ASD-CC Worry/Depressed factor had strong relationships with the BASC-2 Anxiety, Depression, and Somatization subscales, moderate relationships with the BASC-2 Atypicality, Hyperactivity, Aggression, and Conduct Problems subscales, and a weak relationship with the BASC-2 Withdrawal subscale. The ASD-CC Avoidant
Table 6 Intercorrelations between ASD-CC and BASC-2 Adaptive subscales (n = 52) BASC-2 subscales
ASD-CC subscales Tantrum Behavior
Adaptability Social Skills Leadership Activities of Daily Living Functional Communication Adaptive Skills Composite
.44** .23 .12 .26 .24 .27
Repetitive Behavior .07 .33* .19 .33* .34* .21
Worry/ Depressed .06 .17 .26 .18 .03 .04
Avoidant Behavior
UnderEating
Conduct
OverEating
.44** .37* .14 .28* .18 .32*
.15 .09 .28 .08 .11 .11
.14 .11 .45** .02 .19 .13
.06 .23 .02 .17 .25 .24
**p < .01, *p < .05. Note: Correlations involving the BASC-2 Leadership subscale have n = 39 due to age limits.
ASD-CC Composite .35** .26 .02 .36** .27 .27
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Behavior factor showed a moderate relationship with the BASC-2 Withdrawal subscale, weak relationships with the BASC-2 Atypicality, Hyperactivity, Depression, Aggression, and Somatization subscales, and a weak negative relationship with the BASC-2 Anxiety subscale. The ASD-CC UnderEating factor was weakly associated with the BASC-2 Conduct Problems and Somatization subscales, and had weak negative associations with the BASC-2 Anxiety and Atypicality subscales. The ASD-CC Conduct factor was strongly associated with the BASC-2 Depression subscale and moderately associated with the BASC-2 Anxiety, Conduct Problems, Aggression, Hyperactivity, Somatization, and Atypicality subscales. The ASD-CC Over-Eating factor showed moderate associations with the BASC-2 Conduct Problems, Atypicality, and Hyperactivity subscales and weak associations with the BASC-2 Aggression, Withdrawal, Somatization, Depression, Withdrawal, and Attention Problems subscales. 3.4. ASD-CC factor and BASC-2 Adaptive subscale correlations The ASD-CC Composite Score showed weak negative convergence with the BASC-2 Adaptive subscales (r = .27). Relationships between the ASD-CC factors and the BASC-2 Adaptive Skills Composite ranged from .32 (Avoidant Behavior) to .13 (Conduct). The ASD-CC Avoidant Behavior factor had a moderate negative relationship with the BASC-2 Adaptive Skills Composite. The ASD-CC Tantrum Behavior, Over-Eating, Repetitive Behavior, and Under-Eating factors showed weak negative relationships with the BASC-2 Adaptive Skills Composite. The ASD-CC Conduct factor had a weak relationship with the BASC-2 Adaptive Skills Composite. Relationships between the BASC-2 Adaptive subscales and the ASD-CC Composite Score ranged from .36 (Activities of Daily Living) to .02 (Leadership). The BASC-2 Activities of Daily Living and Adaptability subscales had moderate negative associations with the ASD-CC Composite Score. The BASC-2 Functional Communication and Social Skills subscales showed weak negative relationships with the ASD-CC Composite Score. Table 6 provides the correlation matrix between ASD-CC factors and BASC-2 Adaptive subscales. Intercorrelations between ASD-CC factors and BASC-2 Adaptive subscales ranged from .44 (BASC2 Adaptability and ASD-CC Tantrum Behavior; BASC-2 Adaptability and ASD-CC Avoidant Behavior) to .45 (BASC-2 Leadership and ASD-CC Conduct). The ASD-CC Tantrum Behavior factor had a moderate negative relationship with the BASC-2 Adaptability subscale and weak negative relationships with the BASC-2 Activities of Daily Living, Functional Communication, Social Skills, and Leadership subscales. The ASD-CC Repetitive Behavior factor showed moderate negative associations with the BASC-2 Functional Communication, Social Skills, and Activities of Daily Living subscales and a weak negative association with the BASC-2 Leadership subscale. The ASD-CC Worry/Depressed factor had weak relationships with the BASC-2 Leadership and Social Skills subscales and a weak negative relationship with the BASC-2 Activities of Daily Living subscale. The ASD-CC Avoidant Behavior factor showed moderate negative relationships with the BASC-2 Adaptability and Social Skills subscales and weak negative relationships with the BASC-2 Functional Communication and Leadership subscales. The ASD-CC Under-Eating factor showed weak negative associations with the BASC-2 Leadership, Adaptability, and Functional Communication subscales. The ASD-CC Conduct factor was moderately associated with the BASC-2 Leadership subscale, weakly associated with the BASC-2 Functional Communication and Social Skills subscales, and had a weak negative association with the BASC-2 Adaptability subscale. The ASD-CC Over-Eating factor showed weak negative associations with the BASC-2 Functional Communication, Social Skills, and Activities of Daily Living subscales. Results of the EFA were promising. A seven-factor solution was optimal. Factor 1 was composed of items consistent with Tantrum Behavior such as easily becoming angry, damaging property, and irritable mood, an area known to be problematic in developmental disabilities (Duncan, Matson, Bamburg, Cherry, & Buckley, 1999; Matson, Dixon, & Matson, 2005; Rojahn, Aman, Matson, & Mayville, 2003; Rojahn, Matson, Naglieri, & Mayville, 2004). Factor 2 represented symptoms consistent with Repetitive Behavior such as those observed with compulsions, tics, or stereotypies. Factor 3 was composed of items consistent with Worry/Depressed mood, such as experiencing excessive worry or concern and feelings of worthlessness or excessive guilt. Factor 4 was comprised of items mainly associated with Avoidant Behavior such as avoiding people, situations, and events, withdrawal from social situations, and exhibiting fear of being around others. Factors 5 and 7 both addressed eating behaviors, with Factor 5 reflecting Under-Eating and Factor 7 reflecting Over-Eating. Lastly, Factor 6
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was composed of items consistent with Conduct Problems such as blaming others for own misdeeds, lying to obtain goods or favors, and being spiteful or revengeful. The factor structure of the ASD-CC appears to be a valid measure of emotional difficulties in children with ASD. More specifically, construct validity was demonstrated for the Tantrum Behavior, Worry/Depressed, Repetitive Behavior, Conduct, and Over-Eating factors and to a lesser extent the Under-Eating factor. Poor correlations were observed between some seemingly related constructs (e.g. Avoidant Behavior factor of the ASD-CC and the Anxiety subscale of the BASC-2); however, this may be a result of the population surveyed exhibiting symptoms of psychopathology different from the typically developing population or a small sample size. ASD are a complex group of disorders characterized by heterogeneous symptom profiles (Matson & Boisjoli, 2007; Matson, Smiroldo, & Bamburg, 1998; Njardvik, Matson, & Cherry, 1999). Adding to the heterogeneity is the high rate of comorbid conditions evident in this population (Coe et al., 1999; Matson-Rush et al., 1999). In order for implementation of the least intrusive yet effective interventions, accurate diagnosis of co-occurring psychopathology is imperative (Advocate, Mayville, & Matson, 2000; Matson, 2007b; Matson & Nebel-Schwalm, 2007a). Few measures exist that have been studied with children displaying ASD, and a paucity of measures have been designed specifically to assess psychopathology in this population. Careful delineation of comorbid symptomatology in the ASD populations by researchers and clinicians is an important first step in identifying these disorders (Matson, 2007a). Further study of co-occurring mental health problems and related symptomatology is an area of much needed attention, particularly with reliable and valid measures across the broad range of developmental disabilities (Matson, LeBlanc, Weinheimer, & Cherry, 1999; Matson & NebelSchwalm, 2007b; Matson & Rivet, 2007; Matson & Wilkins, 2007; Paclawskyj, Rush, Matson, & Cherry, 1999). The ASD-CC appears to be an appropriate measure for these purposes for children with ASD. References Achenbach, T. M., Rescorla, L. A., & Maruish, M. E. (2004). The Achenbach System of Empirically Based Assessment (ASEBA) for ages 1.5–18 years The use of psychological testing for treatment planning and outcomes assessment, Vol. 2: Instruments for children and adolescents, (3rd ed.). Mahwah, NJ, US: Lawrence Erlbaum Associates Publishers. pp. 179–213. Advocate, C. D., Mayville, E. A., & Matson, J. L. (2000). Side effects profiles of atypical antipsychotics, typical antipsychotics, or no psychotics in persons with mental retardation. Research in Developmental Disabilities, 21, 75–84. Aman, M. G., Tasse´, M. J., Rojahn, J., & Hammer, D. (1996). The Nisonger CBRF: A child behavior rating form for children with developmental disabilities. Research in Developmental Disabilities, 17, 41–57. American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders-Text Revision (4th ed.). Washington, D.C. Author. Applegate, H., Matson, J. L., & Cherry, K. E. (1999). An evaluation of functional variables affecting severe problem behaviors in adults with mental retardation by using the Questions about Behavioral Function Scale (QABF). Research in Developmental Disabilities, 20, 229–237. Campbell, D. T., & Fiske, D. W. (1959). Convergent and discriminant validation by the multitrait–multimethod matrix. Psychological Bulletin, 56, 81–105. Cherry, K. E., Matson, J. L., & Paclawskyj, T. R. (1997). Psychopathology in older adults with severe and profound mental retardation. American Journal on Mental Retardation, 101, 445–458. Coe, D. A., Matson, J. L., Russell, D. W., Slifer, K. J., Capone, G. T., Baglio, C., et al. (1999). Behavior problems of children with Down syndrome and life events. Journal of Autism and Developmental Disorders, 29, 149–156. Comrey, A. L. (1988). Factor-analytic methods of scale development in personality and clinical psychology. Journal of Consulting and Clinical Psychology, 56, 754. Costello, A. B., & Osborne, J. W. (2005). Best practices in exploratory factor analysis: Four recommendations for getting the most from your analysis. Practical Assessment, Research, & Evaluation, 10, 1–9. Dominick, K. C., Davis, N. O., Lainhart, J., Tager-Flusberg, H., & Folstein, S. (2007). Atypical behaviors in children with autism and children with a history of language impairment. Research in Developmental Disabilities, 28, 145–162. Duncan, D., Matson, J. L., Bamburg, J. W., Cherry, K. E., & Buckley, T. (1999). The relationship of self-injurious behavior and aggression to social skills in persons with severe and profound learning disability. Research in Developmental Disabilities, 20, 441–448. Floyd, F. J., & Widaman, K. F. (1995). Factor analysis in the development and refinement of clinical assessment instruments. Psychological Assessment, 7, 286–299. Fombonne, E. (2003). Epidemiological surveys of autism and other pervasive developmental disorders: An update. Journal of Autism and Developmental Disorders, 33, 365–382. Gadow, K. D., & DeVincent, C. J. (2005). Clinical significance of tics and attention-deficit hyperactivity disorder (ADHD) in children with pervasive developmental disorder. Journal of Child Neurology, 20, 481–488. Gadow, K. D., DeVincent, C. J., Pomeroy, J., & Azizian, A. (2004). Psychiatric symptoms in preschool children with PDD and clinic comparison samples. Journal of Autism and Developmental Disorders, 34, 379–393. Gadow, K. D., & Sprafkin, J. (1998). Child Symptom Inventory-4 screening manual. Stony Brook, NY: Checkmate Plus. Ghaziuddin, M. (2000). A family history study of Asperger syndrome. Journal of Autism and Developmental Disorders, 35, 177–182.
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Ghaziuddin, M., Tsai, L., & Ghaziuddin, N. (1992). Comorbidity of autistic disorder. European Journal of Child and Adolescent Psychiatry, 1, 209–213. Goldstein, G., & Schwebach, A. J. (2004). The comorbidity of Pervasive Developmental Disorder and Attention Deficit Hyperactivity Disorder: Results of a retrospective chart review. Journal of Autism and Developmental Disorders, 34, 329–339. Hollander, E., King, A., Delaney, K., Smith, C. J., & Silverman, J. M. (2003). Obsessive-compulsive behaviors in parents of multiplex autism families. Psychiatry Research, 117, 11–16. Lecavalier, L., Aman, M. G., Hammer, D., Stocia, W., & Mathews, G. L. (2004). Factor analysis of the Nisonger Child Behavior rating form in children with autism spectrum disorders. Journal of Autism and Developmental Disorders, 34, 709–721. Matson, J. L. (2007a). Current status of differential diagnosis for children with autism spectrum disorders. Research in Developmental Disabilities, 28, 109–118. Matson, J. L. (2007b). Determining treatment outcome in early intervention programs for autism spectrum disorders: A critical analysis of measurement issues in learning based interventions. Research in Developmental Disabilities, 28, 207–218. Matson, J. L., Baglio, C. S., Smiroldo, B. B., Hamilton, M., Packlowskyj, T., Williams, D., et al. (1996). Characteristics of autism as assessed by the Diagnostic Assessment for the Severely Handicapped-II (DASH-II). Research in Developmental Disabilities, 17, 135–143. Matson, J. L., & Bamburg, J. W. (1998). Reliability of the Assessment of Dual Diagnosis (ADD). Research in Developmental Disabilities, 19, 89–95. Matson, J. L., & Boisjoli, J. A. (2007). Autism spectrum disorders in adults with intellectual disability and comorbid psychopathology: Scale development and reliability of the ASD-CA. Research in Autism Spectrum Disorders, 2, 276–287. 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., Dixon, D. R., & Matson, M. L. (2005). Assessment and treatment of aggressive behavior in children and adolescents with developmental disabilities. Journal of Educational Psychology, 25, 151–181. Matson, J. L., Gonzalez, M. L., Wilkins, J., & Rivet, T. T. (2007). Reliability of the Autism Spectrum Disorder-Diagnosis for Children (ASDDC). Research in Autism Spectrum Disorders, 2, 533–545. Matson, J. L., LeBlanc, L. A., Weinheimer, B., & Cherry, K. E. (1999). Reliability of the Matson Evaluation of Social Skills for Individuals with Severe Retardation (MESSIER). Behavior Modification, 23, 647–661. Matson, J. L., & Logan, J. R. (1997). A review of destructive behavior in developmental disabilities: Diagnosis and treatment. Contemporary Psychology, 42, 545–546. Matson, J. L., & Love, S. R. (1990). A comparison of parent-reported fear for autistic and non-handicapped age-matched children and youth. Australia & New Zealand Journal of Developmental Disabilities, 16, 349–357. Matson, J. L., & Nebel-Schwalm, M. S. (2007a). Assessing challenging behaviors in children with autism spectrum disorders: A review. Research in Developmental Disabilities, 28, 567–579. Matson, J. L., & Nebel-Schwalm, M. S. (2007b). Comorbid psychopathology with autism spectrum disorder in children: An overview. Research in Developmental Disabilities, 28, 341–352. Matson, J. L., & Rivet, T. T. (2007). A validity study of the Autism Spectrum Disorders-Behavior Problems for Adults (ASD-BPA) scale. Journal of Developmental and Physical Disabilities, 19, 557–564. Matson, J. L., Rush, K. S., Hamilton, M., Anderson, S. J., Bamburg, J. W., & Baglio, C. S. (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., & Smiroldo, B. B. (1997). Validity of the Mania subscale of the Diagnostic Assessment for the Severely Handicapped-II (DASH-II). Research in Developmental Disabilities, 18, 221–225. Matson, J. L., Smiroldo, B. B., & Bamburg, J. W. (1998a). The relationship of social skills to psychopathology for individuals with severe or profound mental retardation. Journal of Intellectual & Developmental Disability, 23, 137–145. Matson, J. L., Smiroldo, B. B., Hamilton, M., & Baglio, C. S. (1997). Do anxiety disorders exist in persons with severe and profound mental retardation? Research in Developmental Disabilities, 18, 39–44. Matson, J. L., Smiroldo, B. B., & Hastings, T. L. (1998b). Validity of the Autism/Pervasive Developmental Disorder subscale of the Diagnostic Assessment for the Severely Handicapped-II. Journal of Autism and Developmental Disorders, 28, 77–81. Matson, J. L., & Wilkins, J. (2007). A critical review of assessment targets and methods for social skills excesses and deficits for children with autism spectrum disorders. Research in Autism Spectrum Disorders, 1, 28–37. Matson, J. L., & Wilkins, J. (2008). Reliability of the Autism Spectrum Disorders-Comorbidity for Children (ASD-CC). Journal of Developmental and Physical Disabilities, 20, 155–165. Njardvik, U., Matson, J. L., & Cherry, K. E. (1999). A comparison of social skills in adults with autistic disorder, Pervasive Developmental Disorder Not Otherwise Specified, and mental retardation. Journal of Autism and Developmental Disorders, 29, 287–295. Paclawskyj, T. R., Matson, J. L., Bamburg, J. W., & 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. Paclawskyj, T. R., Rush, K. S., Matson, J. L., & Cherry, K. E. (1999). Factor structure of the Matson Evaluation of Social Skills for Individuals with Severe Retardation (MESSIER). British Journal of Clinical Psychology, 38, 289–293. Prizant, B. M. (1996). Brief report: Communication, language, social, and emotional development. Journal of Autism and Developmental Disorders, 26, 173–178. Reynolds, C. R., & Kamphaus, R. W. (2004). Manual: Behavior Assessment System for Children-Second Edition. Circle Pines, MN: American Guidance Service. Rojahn, J., Aman, M. G., Matson, J. L., & Mayville, E. A. (2003). The Aberrant Behavior Checklist and Behavior Problems Inventory: Convergent and divergent validity. Research in Developmental Disabilities, 24, 391–404. Rojahn, J., Matson, J. L., Lott, D., Esbensen, A. J., & Smalls, Y. (2001). The Behavior Problems Inventory: An instrument for the assessment of self-injury, stereotyped behavior, and aggression/destruction in individuals with developmental disabilities. Journal of Autism and Developmental Disorders, 31, 577–588. Rojahn, J., Matson, J. L., Naglieri, J. A., & Mayville, E. A. (2004). Relationships between psychiatric conditions and behavior problems among adults with mental retardation. American Journal on Mental Retardation, 109, 21–33. Siklos, S., & Kerns, K. A. (2007). Assessing the diagnostic experiences of a small sample of parents of children with autism spectrum disorders. Research in Developmental Disabilities, 28, 9–22.
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Singh, A. N., Matson, J. L., Cooper, C. L., Dixon, D. R., & Sturmey, P. (2005). The use of risperidone among individuals with mental retardation: Clinically supported or not? Research in Developmental Disabilities, 26, 203–218. Sprafkin, J., Volpe, R. J., Gadow, K. D., Nolan, E. E., & Kelly, K. (2002). A DSM-IV-referenced screening instrument for preschool children: The Early Childhood Inventory-4. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 604–612. Tantum, D. (2000). Psychological disorders in adolescents and adults with Asperger’s syndrome. Autism, 4, 47–62. World Health Organization. (1992). International classification of diseases (10th ed.). Geneva, Switzerland: Author. Wozniak, J., Biederman, J., Faraone, S. V., Frazier, J., Kim, J., Millstein, R., et al. (1997). Mania in children with pervasive developmental disorder revisited. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1552–1560.
Contents lists available at ScienceDirect
Research in Autism Spectrum Disorders Journal homepage: http://ees.elsevier.com/RASD/default.asp
Validity of the Autism Spectrum Disorder-Comorbid for Children (ASD-CC) Johnny L. Matson *, Santino V. LoVullo, Tessa T. Rivet, Jessica A. Boisjoli Department of Psychology, Louisiana State University, Baton Rouge, LA 70803, United States
A R T I C L E I N F O
A B S T R A C T
Keywords: ASD Autism Comorbid Assessment
A limited number of studies currently exist focusing on comorbid psychopathology of children with autism spectrum disorders (ASDs). Due to the heterogeneity of ASD symptoms, communication deficits, and impairments in intellectual functioning, assessing symptoms of psychopathology is complicated. The Autism Spectrum Disorders-Comorbidity for Children (ASD-CC) is a new measure, incorporated in an extensive assessment battery, designed to assess children with ASD for comorbid psychopathology. Reliability analyses of the ASD-CC have been conducted [Matson, J. L., & Wilkins, J. (2008). Reliability of the Autism Spectrum Disorders-Comorbidity for Children (ASD-CC). Journal of Developmental and Physical Disabilities, 20, 155–165]. The aim of this study was to identify the factor structure of the ASD-CC and evaluate construct validity of the measure by correlating the empirically derived factors with subscales of the Behavioral Assessment System for Children, Version 2 (BASC-2). Results of the analyses included a seven-factor solution. The factors were composed of items consistent with Tantrum Behavior, Repetitive Behavior, Worry/Depressed, Avoidant Behavior, Under-Eating, Over-Eating, and Conduct. Convergence between some factors of the ASD-CC and related subscales was observed as was discrimination between unrelated factors of the two measures. The ASD-CC appears to be a valid measure of comorbid psychopathology in the ASD population. ß 2008 Elsevier Ltd. All rights reserved.
* Corresponding author. E-mail address: [email protected] (J.L. Matson). 1750-9467/$ – see front matter ß 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.rasd.2008.08.002
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1. Introduction Autism Spectrum Disorders (ASDs) are a group of neurodevelopmental disorders characterized by impairments in three core domains: socialization, communication, and repetitive behaviors/instance on sameness. While each child with ASD evinces deficits in socialization, and deficits in communication and/or behavioral disturbances, heterogeneity in the presentation of symptoms is common to this population, making differential diagnosis difficult (Siklos & Kerns, 2007). To further complicate the diagnostic picture, children with ASD often display maladaptive behaviors such as physical aggression, noncompliance, and pica (Applegate, Matson, & Cherry, 1999; Dominick, Davis, Lainhart, Tager-Flusberg, & Folstein, 2007; Matson & Logan, 1997), as well as genetic disorders and other forms of psychopathology (Matson & Nebel-Schwalm, 2007b). The term comorbidity refers to the co-occurrence of more than one form of psychopathology in the same person (Matson & Bamburg, 1998; Matson & Nebel-Schwalm, 2007b; Singh, Matson, Cooper, Dixon, & Sturmey, 2005). One of the more commonly studied comorbid disorders with ASD is intellectual disability (ID). Up to 70% of children diagnosed with autism also have ID (Fombonne, 2003). For the purposes of this article, we refer to comorbidity as ASD co-occurring with another mental health disorder not including ID. Less studied disorders co-occurring with ASD include anxiety, fears, tics, depression, mania, and attention problems (Gadow & DeVincent, 2005; Gadow, DeVincent, Pomeroy, & Azizian, 2004; Ghaziuddin, Tsai, & Ghaziuddin, 1992; Goldstein & Schwebach, 2004; Matson & Love, 1990; Matson, Smiroldo, Hamilton, & Baglio, 1997; Tantum, 2000; Wozniak et al., 1997). Other disorders, such as obsessive compulsive disorder (OCD) and depression, have been reported to occur at higher rates in family members of people diagnosed with ASD than in the general population (Ghaziuddin, 2000; Hollander, King, Delaney, Smith, & Silverman, 2003). The presence of comorbid psychopathology in this population necessitates further study (Rojahn, Matson, Lott, Esbensen, & Smalls, 2001). The literature base on the co-occurrence of ASD and other forms of psychopathology is drawn from a limited number of small-scale studies. One difficulty in identifying comorbid conditions in this particular population is distinguishing symptoms of psychopathology from core features of ASD (Matson et al., 1996; Matson, Smiroldo, & Hastings, 1998; Paclawskyj, Matson, Bamburg, & Baglio, 1997). People with ASD exhibit behaviors such as restricted interests, rituals, and stereotypies that may look topographically similar to obsessions, compulsions, or tics, for example. They may also exhibit a restricted range of facial expression and have limited verbal ability complicating assessment. Another difficulty in the assessment of psychopathology in people with ASD is communication deficits characteristic of this disorder. Approximately half of all people diagnosed with an ASD never develop speech (Prizant, 1996). Of the half who do talk, the speech may be limited in functional content. Tied into the communication deficits in children with ASD is the confounding diagnosis of ID in many children. With increasing severity of ID, verbal ability decreases and self-report may not be feasible (Cherry, Matson, & Paclawskyj, 1997; Matson & Smiroldo, 1997). Clinicians are often left to rely on parent/caretaker report and/or behavioral observation to identify psychopathology in this population. Parent/caretaker rating scales are used for this purpose. Numerous scales exist to assess the core symptoms of ASD; however, very few are available to assess symptoms of psychopathology in this population. Of the available tests for assessing psychopathology in the typically developing and ID populations, many have not been researched specifically with children with ASD. Parent/teacher report measures such as the Early Childhood Inventory-4 (ECI-4) (Sprafkin, Volpe, Gadow, Nolan, & Kelly, 2002), the Child Symptom Inventory-4 (CSI4) (Gadow & Sprafkin, 1998), and the Diagnostic Interview Schedule for Children (DISC) have been used with children with ASD. However, the psychometric properties of the scales have yet to be established with this population. The Nisonger Child Behavior Rating Forms (NCBRF) (Aman, Tasse´, Rojahn, & Hammer, 1996) is an exception in that it has been evaluated with the ASD population including a factor analysis which resulted in a different structure than the original factor analysis of children with ID (Lecavalier, Aman, Hammer, Stocia, & Mathews, 2004). Because of these limitations a new measure, the Autism Spectrum Disorders-Comorbidity for Children (ASD-CC), was developed to specifically assess children diagnosed with an ASD for comorbid psychopathology. Given the requirements of disorder
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specific assessment for the ASD population and the frequency with which it occurs in the general population, such a scale seemed warranted. Initial research with the ASD-CC shows promise, however, the scale is still in the initial stages of development (Matson & Wilkins, 2008). The aim of this study was to establish the factor structure of the ASD-CC using exploratory factor analysis and evaluate the construct validity of the measure by examining intercorrelations of the empirically derived factors of the ASD-CC. 2. Method 2.1. Participants Participants were recruited throughout the United States from a variety of clinic and school settings, as well as community organizations. Recruitment was based on self or professional referral. Typically developing children and children with developmental disorders were recruited. The project was described as a study on the development of measures to assess autism spectrum disorders and cooccurring problems. IRB approval and informed consent from parents/guardians were obtained. The sample included 311 children and adolescents. One hundred and thirty-four of the participants were excluded due to failure to meet inclusion criteria of an ASD diagnosis (see below for inclusion criteria). The final sample included 177 children and adolescents between 2 and 17 years of age (M = 8.51, S.D. = 3.95). Sixty-two percent of the children were Caucasian, 8% were African American, and 3% were Hispanic, with the remainder of the sample having other or unspecified races. The majority of children were male (78%) and had some verbal skills (60%). Twelve percent of children were identified by informants as having an ID. Twenty-nine percent of the participants were prescribed one or more psychotropic medications at the time the measures were completed. In order to determine inclusion criteria and standardize ASD diagnoses across sites, a composite symptom checklist from the DSM-IV-TR (American Psychiatric Association, 2000) and International Classification of Diseases, Tenth Edition (World Health Organization, 1992) was used. Two deficits in social interaction and one in another area of functioning (e.g. communication or repetitive behaviors/ interests) were required and a diagnosis by a licensed Ph.D. level clinical psychologist for inclusion in the study. Inter-rater reliability, test–retest reliability, and internal consistency (r = .89; r = .96; a = .95, respectively) of the checklist for a subset of the sample proved excellent (Matson, Gonzalez, Wilkins, & Rivet, 2007). Five children had previous ASD diagnoses, but were excluded because they did not meet the research criteria described for this study. According to parent report, ASD diagnoses were Autistic disorder (37%), PDDNOS (18%), and Asperger’s disorder (8%), with 15% not reporting a specific ASD. Additional diagnoses included nonverbal learning disability, anxiety disorders, attention deficit/hyperactivity disorder (ADHD), bipolar disorder, depression, developmental delay, Down’s syndrome, fetal alcohol syndrome, Fragile X Syndrome, learning disorders, language disorders, sensory integration dysfunction, oppositional defiant disorder, seizure disorder, stereotypic movement disorder, tics, selective mutism, psychosis, and psychopathology (unspecified). 2.2. Test materials Parents or caregivers completed the ASD-CC and DSM-IV-TR/ICD-10 checklist independently according to the directions printed at the top of the questionnaire. Doctoral students in clinical psychology were available to help resolve any questions parents had while completing the measure. 2.3. Autism Spectrum Disorders-Comorbid for Children The ASD-CC is a 49-item, informant-based rating scale designed to assess symptoms of emotional difficulties which commonly occur with ASD. Items encompass comorbid conditions such as depression, conduct disorder, ADHD, tic disorder, OCD, specific phobia, and eating difficulties. Caregivers rate each item to the extent that it has been a recent problem as either 0 = ‘‘not a problem or impairment; not at all,’’ 1 = ‘‘mild problem or impairment,’’ 2 = ‘‘severe problem or impairment,’’ or
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X = ‘‘does not apply or don’t know.’’ The ASD-CC has been found to have moderately good inter-rater (k = .46) and test–retest reliability (k = .51) and very good internal consistency (a = .91; Matson & Dempsey, 2008). Behavior Assessment System for Children-2 (BASC-2; Reynolds & Kamphaus, 2004). The BASC-2 is a broad-band assessment of clinical and adaptive dimensions for children ages 2–21 years. The BASC-2 was chosen as a comparison in evaluating the construct validity of the ASD-CC because it provides norms and distinct clinical profiles for children with ASD and other childhood disorders. The present study utilized the BASC-2 parent-rating forms, which are comprised of three versions: preschool (ages 2–5), child (ages 6–11), and adolescent (ages 12–21). Items are rated from 1 (never) to 4 (almost always). The dimensions rated include: aggression, hyperactivity, conduct problems, anxiety, depression, somatization, attention problems, learning problems, atypicality, withdrawal, adaptability, activities of daily living, functional communication, leadership, social skills, and study skills. Authors of the BASC-2 report internal consistency as high (ranging from a = .85 to .95 for general samples and .89–.95 for clinical samples), test–retest reliability ranging from .76 to .92, and inter-rater reliability ranging from .70 to .88. In addition, concurrent validity was high with the Child Behavior Checklist (Achenbach, Rescorla, & Maruish, 2004). 3. Results and discussion First, an exploratory factor analysis using principal axis factoring for extraction and a promax rotation was computed with the items of the ASD-CC. Factor loadings are generally considered meaningful when exceeding .30 or .40 (Floyd & Widaman, 1995). A combination of methods was used to determine the number of factors extracted, including the scree plot, eigenvalues, number of items per factor, simple structure, and interpretability (Comrey, 1988; Costello & Osborne, 2005; Floyd & Widaman, 1995). Internal consistency of the ASD-CC factors and overall scale were computed. Next, Pearson correlations were computed between the ASD-CC factors. Inter-subscale correlations were also computed separately for the BASC-2 Clinical and Adaptive subscales. Finally, correlations were computed to establish convergent and discriminate validity of the ASD-CC factors with the clinical and adaptive subscales of the BASC-2 (Campbell & Fiske, 1959). It was hypothesized that the ASD-CC would show overall convergence with related ASD-CC factors and BASC-2 Clinical subscales and overall discrimination with unrelated factors of the ASD-CC and BASC-2. 3.1. Factor analysis For the initial factor analysis of the 49 items of the ASD-CC, the Kaiser–Meyer–Olkin (KMO) index of sampling adequacy was .79, and the test of sphericity was highly significant (p < .001), indicating that the data were acceptable for factor analysis. In addition, communalities ranged from .33 to .70. A seven-factor solution was selected by considering multiple criteria, as outlined above. The sevenfactor solution, also conducted using principal axis factoring with a promax rotation, accounted for 42.64% of the variance. Factor 1 (Tantrum Behavior) accounted for 18.82% of the variance, Factor 2 (Repetitive Behavior) accounted for 6.69%, Factor 3 (Worry/Depressed) accounted for 4.76%, Factor 4 (Avoidant Behavior) accounted for 4.00%, Factor 5 (Under-Eating) accounted for 3.56%, Factor 6 (Conduct) accounted for 2.69%, and Factor 7 (Over-Eating) accounted for 2.13%. Factor correlations ranged from .00 to .54. One item (Tearful or weepy) cross-loaded on Factors 1 and 3, but was rationally assigned to Factor 3 as it conceptually fit better with the Worry/Depressed factor. Ten items were removed because their factor loadings failed to meet a minimum criterion of .40. The pattern matrix for the seven-factor solution is presented in Table 1. Internal consistency was calculated for the ASD-CC factors. The exclusion of any item did not result in a substantial increase in a for any of the factors. a, scale means and standard deviations were as follows for the seven factors: Tantrum Behavior (a = .86; M = 7.41, S.D. = 4.48), Repetitive Behavior (a = .75; M = 5.06, S.D. = 3.52), Worry/Depressed (a = .74; M = 2.12, S.D. = 2.34), Avoidant Behavior (a = .77; M = 3.85, S.D. = 2.97), Under-Eating (a = .78; M = 1.01, S.D. = 1.54), Conduct (a = .74; M = 1.33, S.D. = 1.78), and Over-Eating (a = .70; M = 1.46, S.D. = 1.67).
Table 1 Factor structure of the ASD-CC Item
47 38 33 12 42 31 36 46 26 16 37 22 27 23 19 6
Tantrums Easily becomes angry Irritable mood Easily becomes upset Crying Tearful or weepy Damages property Compliance with demands Finishes assigned tasks Destroys other’s property Sudden, rapid, repetitive movements or vocalizations that are not associated with a physical disability Sudden, rapid, repetitive movement or vocalization that occurs for no apparent reason Persistent or recurring impulses that interfere with activities Checking on play objects excessively Engages in repetitive behaviors Eats things that are not meant to be eaten Engages in behaviors that impair daily routine or activities. Fidgets or squirms Experiences excessive worry or concern Feelings of worthlessness or excessive guilt Has persistent or recurring thoughts that cause distress Low energy or fatigue Loses belongings Avoids specific objects, persons, or situations causing interference with his/her normal routine Avoids specific situations, people, or events Withdraws or removes him/her self from social situations Will eat only certain foods
Factor 2 (Repetitive Behavior)
.74 .72 .72 .63 .61 .60 .51 .48 .43 .43
Factor 3 (Worry/ Depressed)
Factor 4 (Avoidant Behavior)
Factor 5 (UnderEating)
Factor 6 (Conduct)
Factor 7 (OverEating)
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35 32 44 1 5 25 21 13 29 7 4
Factor 1 (Tantrum Behavior)
.40
.68
.62 .55 .54 .50 .44 .42 .41 .67 .56 .50 .49 .48 .71 .68 .59 .54
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350
Item
3 20 14 18 28 8 9 17 49 2 11 48
Factor 1 (Tantrum Behavior) Fear of being around others in school, at home, or social situations Has trouble sleeping Has a poor appetite Eats too little Weight loss Blames others for his/her misdeeds Lies to obtain goods or favors Spiteful, vindictive, revengeful, or wants to get back at others Blurts out comments or words at inappropriate times Eats too much Weight gain Eats too quickly
Factor 2 (Repetitive Behavior)
Factor 3 (Worry/ Depressed)
Factor 4 (Avoidant Behavior)
Factor 5 (UnderEating)
Factor 6 (Conduct)
Factor 7 (OverEating)
.49 .40 .88 .81 .58 .79 .73 .67 .40 .69 .62 .48
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Table 1 (Continued )
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Table 2 Intercorrelations between ASD-CC subscales (n = 178) ASD-CC subscales
ASD-CC subscales Factor 1 (Tantrum Behavior)
Factor 1 (Tantrum Behavior) Factor 2 (Repetitive Behavior) Factor 3 (Worry/Depressed) Factor 4 (Avoidant Behavior) Factor 5 (Under-Eating) Factor 6 (Conduct) Factor 7 (Over-Eating) ASD-CC Composite
–
Factor 2 (Repetitive Behavior) .46** –
Factor 3 (Worry/ Depressed)
Factor 4 (Avoidant Behavior)
Factor 5 (UnderEating)
Factor 6 (Conduct)
Factor 7 (OverEating)
ASD-CC Composite
.29**
.42**
.02**
.48**
.35**
.82**
.11**
.30**
.05**
.24**
.24**
.66**
.31**
.15**
.52**
.29**
.58**
.18**
.30**
.18**
.62**
.10** –
.02** .24** –
.23** .65** .51** –
–
– –
**p < .01.
3.2. Intercorrelations Intercorrelations between the seven factors of the ASD-CC were calculated. Correlations between each factor and the ASD-CC Composite Score ranged from .23 (Under-Eating) to .82 (Tantrum Behavior). Inter-factor correlations ranged from .02 (Under-Eating and Over-Eating; Under-Eating and Tantrum Behavior) to .48 (Tantrum Behavior and Conduct). Intercorrelations between the BASC-2 Clinical subscales were also calculated. Correlations between each subscale and the BASC-2 Behavioral Symptoms Index (BSI) ranged from .30 (Anxiety) and .72 (Hyperactivity). Inter-subscale correlations ranged from .01 (Attention Problems and Anxiety) to .78 (Anxiety and Depression). Lastly, intercorrelations were computed between the BASC-2 Adaptive subscales. Correlations between each subscale and the BASC-2 Adaptive Skills Composite ranged from .53 (Adaptability) to .80 (Social Skills). Inter-subscale correlations ranged from .23 (Adaptability and Leadership) to .66 (Social Skills and Leadership; Social Skills and Functional Communication). Table 2 provides intercorrelations between the ASD-CC factors, Table 3 provides intercorrelations between the BASC-2 Clinical subscales, and Table 4 provides intercorrelations between the BASC-2 Adaptive subscales. 3.3. ASD-CC factor and BASC-2 Clinical subscale correlations The ASD-CC Composite Score showed strong convergence with the BASC-2 Clinical subscales (r = .66). Relationships between the ASD-CC factors and the BASC-2 BSI ranged from .13 (UnderEating) to .63 (Tantrum Behavior). The ASD-CC Tantrum Behavior factor was strongly associated with the BASC-2 BSI. The ASD-CC Over-Eating, Worry/Depressed, Conduct, and Avoidant Behavior factors showed moderate relationships with the BASC-2 BSI. The ASD-CC Repetitive Behavior factor had a weak relationship with the BASC-2 BSI, and the ASD-CC Under-Eating factor had a weak negative relationship with the BASC-2 BSI. Relationships between the BASC-2 subscales and the ASD-CC Composite Score ranged from .19 (Anxiety) to .61 (Atypicality). The BASC-2 Atypicality and Hyperactivity subscales were strongly associated with the ASD-CC Composite Score. The BASC-2 Aggression, Depression, Somatization, and Conduct Problems subscales were moderately associated with the ASD-CC Composite Score. The BASC-2 Attention Problems, Withdrawal, and Anxiety subscales had weak relationships with the ASD-CC Composite Score. Table 5 provides the correlation matrix between ASD-CC factors and BASC-2 Clinical subscales, including the ASD-CC Composite Score and the BASC-2 BSI. Intercorrelations between ASD-CC factors and BASC-2 Clinical subscales ranged from .22 (BASC-2 Anxiety and ASD-CC Repetitive Behavior) to .68 (BASC-2 Anxiety and ASD-CC Worry/Depressed). The ASD-CC Tantrum Behavior factor showed strong relationships with the BASC-2 Hyperactivity and
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BASC-2 subscales
BASC-2 Clinical subscales
Hyperactivity Aggression Conduct Anxiety Depression Somatization Atypicality Withdrawal Attention BASC-2 BSI
.67** –
Aggression
Conduct Problems .70** .60** –
Anxiety
Depression
Somatization
Atypicality
Withdrawal
Attention Problems
BASC-2 BSI
.34* .41** .38* –
.58** .63** .62** .78** –
.41** .41** .46** .49** .61** –
.37** .29* .28 .02 .26 .32* –
.03 .11 .04 .03 .18 .12 .41** –
.40** .28* .47** .01 .23 .18 .34* .17 –
.72** .70** .47** .30* .57** .46** .74** .50** .45** –
**p < .01, *p < .05. Note: Correlations involving the BASC-2 Conduct Problems subscale have n = 39 due to age limits.
J.L. Matson et al. / Research in Autism Spectrum Disorders 3 (2009) 345–357
Table 3 Intercorrelations between BASC-2 Clinical subscales (n = 52)
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Table 4 Intercorrelations between BASC-2 Adaptive subscales (n = 52) BASC-2 subscales
BASC-2 Adaptive subscales
Adaptability Social Skills Leadership Activities of Daily Living Functional Communication Adaptive Skills Composite
Adaptability
Social Skills
Leadership
Activities of Daily Living
Functional Communication
Adaptive Skills Composite
–
.38** –
.23 .66** –
.38** .59** .64** –
.26 .66** .63** .58** –
.53** .80** .66** .78** .79** –
**p < .01, *p < .05. Note: Correlations involving the BASC-2 Leadership subscale have n = 39 due to age limits.
Table 5 Intercorrelations between ASD-CC and BASC-2 Clinical subscales (n = 52) BASC-2 subscales
ASD-CC subscales Tantrum Behavior
Hyperactivity Aggression Conduct Problems Anxiety Depression Somatization Atypicality Withdrawal Attention Problems BASC-2 BSI
Repetitive Behavior
.57** .54** .34* .12 .32* .26 .49** .17 .36** .63**
.30* .12 .25 .22 .00 .24 .48** .03 .26 .29*
Worry/ Depressed
Avoidant Behavior
.32* .32* .30 .68** .66** .52** .33* .18 .07 .44**
.16 .13 .05 .12 .16 .12 .27* .32* .04 .30*
UnderEating
Conduct
.02 .03 .21 .11 .09 .14 .10 .00 .00 .13
.40** .43** .44** .48** .56** .39** .31* .01 .07 .43**
OverEating .33* .28* .46** .02 .24 .25 .42** .27 .17 .44**
ASD-CC Composite .58** .49** .44** .19 .47** .47** .61** .21 .28* .66**
**p < .01, *p < .05. Note: Correlations involving the BASC-2 Conduct Problems subscale have n = 39 due to age limits.
Aggression subscales, moderate relationships with the BASC-2 Atypicality, Attention Problems, Conduct Problems, and Depression subscales, and weak relationships with the BASC-2 Somatization, Withdrawal, and Anxiety subscales. The ASD-CC Repetitive Behavior factor was moderately associated with the BASC-2 Atypicality and Hyperactivity subscales, weakly associated with the BASC-2 Attention Problems, Hyperactivity, Conduct Problems, Somatization, and Aggression subscales, and had a weak negative association with the BASC-2 Anxiety subscale. The ASD-CC Worry/Depressed factor had strong relationships with the BASC-2 Anxiety, Depression, and Somatization subscales, moderate relationships with the BASC-2 Atypicality, Hyperactivity, Aggression, and Conduct Problems subscales, and a weak relationship with the BASC-2 Withdrawal subscale. The ASD-CC Avoidant
Table 6 Intercorrelations between ASD-CC and BASC-2 Adaptive subscales (n = 52) BASC-2 subscales
ASD-CC subscales Tantrum Behavior
Adaptability Social Skills Leadership Activities of Daily Living Functional Communication Adaptive Skills Composite
.44** .23 .12 .26 .24 .27
Repetitive Behavior .07 .33* .19 .33* .34* .21
Worry/ Depressed .06 .17 .26 .18 .03 .04
Avoidant Behavior
UnderEating
Conduct
OverEating
.44** .37* .14 .28* .18 .32*
.15 .09 .28 .08 .11 .11
.14 .11 .45** .02 .19 .13
.06 .23 .02 .17 .25 .24
**p < .01, *p < .05. Note: Correlations involving the BASC-2 Leadership subscale have n = 39 due to age limits.
ASD-CC Composite .35** .26 .02 .36** .27 .27
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Behavior factor showed a moderate relationship with the BASC-2 Withdrawal subscale, weak relationships with the BASC-2 Atypicality, Hyperactivity, Depression, Aggression, and Somatization subscales, and a weak negative relationship with the BASC-2 Anxiety subscale. The ASD-CC UnderEating factor was weakly associated with the BASC-2 Conduct Problems and Somatization subscales, and had weak negative associations with the BASC-2 Anxiety and Atypicality subscales. The ASD-CC Conduct factor was strongly associated with the BASC-2 Depression subscale and moderately associated with the BASC-2 Anxiety, Conduct Problems, Aggression, Hyperactivity, Somatization, and Atypicality subscales. The ASD-CC Over-Eating factor showed moderate associations with the BASC-2 Conduct Problems, Atypicality, and Hyperactivity subscales and weak associations with the BASC-2 Aggression, Withdrawal, Somatization, Depression, Withdrawal, and Attention Problems subscales. 3.4. ASD-CC factor and BASC-2 Adaptive subscale correlations The ASD-CC Composite Score showed weak negative convergence with the BASC-2 Adaptive subscales (r = .27). Relationships between the ASD-CC factors and the BASC-2 Adaptive Skills Composite ranged from .32 (Avoidant Behavior) to .13 (Conduct). The ASD-CC Avoidant Behavior factor had a moderate negative relationship with the BASC-2 Adaptive Skills Composite. The ASD-CC Tantrum Behavior, Over-Eating, Repetitive Behavior, and Under-Eating factors showed weak negative relationships with the BASC-2 Adaptive Skills Composite. The ASD-CC Conduct factor had a weak relationship with the BASC-2 Adaptive Skills Composite. Relationships between the BASC-2 Adaptive subscales and the ASD-CC Composite Score ranged from .36 (Activities of Daily Living) to .02 (Leadership). The BASC-2 Activities of Daily Living and Adaptability subscales had moderate negative associations with the ASD-CC Composite Score. The BASC-2 Functional Communication and Social Skills subscales showed weak negative relationships with the ASD-CC Composite Score. Table 6 provides the correlation matrix between ASD-CC factors and BASC-2 Adaptive subscales. Intercorrelations between ASD-CC factors and BASC-2 Adaptive subscales ranged from .44 (BASC2 Adaptability and ASD-CC Tantrum Behavior; BASC-2 Adaptability and ASD-CC Avoidant Behavior) to .45 (BASC-2 Leadership and ASD-CC Conduct). The ASD-CC Tantrum Behavior factor had a moderate negative relationship with the BASC-2 Adaptability subscale and weak negative relationships with the BASC-2 Activities of Daily Living, Functional Communication, Social Skills, and Leadership subscales. The ASD-CC Repetitive Behavior factor showed moderate negative associations with the BASC-2 Functional Communication, Social Skills, and Activities of Daily Living subscales and a weak negative association with the BASC-2 Leadership subscale. The ASD-CC Worry/Depressed factor had weak relationships with the BASC-2 Leadership and Social Skills subscales and a weak negative relationship with the BASC-2 Activities of Daily Living subscale. The ASD-CC Avoidant Behavior factor showed moderate negative relationships with the BASC-2 Adaptability and Social Skills subscales and weak negative relationships with the BASC-2 Functional Communication and Leadership subscales. The ASD-CC Under-Eating factor showed weak negative associations with the BASC-2 Leadership, Adaptability, and Functional Communication subscales. The ASD-CC Conduct factor was moderately associated with the BASC-2 Leadership subscale, weakly associated with the BASC-2 Functional Communication and Social Skills subscales, and had a weak negative association with the BASC-2 Adaptability subscale. The ASD-CC Over-Eating factor showed weak negative associations with the BASC-2 Functional Communication, Social Skills, and Activities of Daily Living subscales. Results of the EFA were promising. A seven-factor solution was optimal. Factor 1 was composed of items consistent with Tantrum Behavior such as easily becoming angry, damaging property, and irritable mood, an area known to be problematic in developmental disabilities (Duncan, Matson, Bamburg, Cherry, & Buckley, 1999; Matson, Dixon, & Matson, 2005; Rojahn, Aman, Matson, & Mayville, 2003; Rojahn, Matson, Naglieri, & Mayville, 2004). Factor 2 represented symptoms consistent with Repetitive Behavior such as those observed with compulsions, tics, or stereotypies. Factor 3 was composed of items consistent with Worry/Depressed mood, such as experiencing excessive worry or concern and feelings of worthlessness or excessive guilt. Factor 4 was comprised of items mainly associated with Avoidant Behavior such as avoiding people, situations, and events, withdrawal from social situations, and exhibiting fear of being around others. Factors 5 and 7 both addressed eating behaviors, with Factor 5 reflecting Under-Eating and Factor 7 reflecting Over-Eating. Lastly, Factor 6
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was composed of items consistent with Conduct Problems such as blaming others for own misdeeds, lying to obtain goods or favors, and being spiteful or revengeful. The factor structure of the ASD-CC appears to be a valid measure of emotional difficulties in children with ASD. More specifically, construct validity was demonstrated for the Tantrum Behavior, Worry/Depressed, Repetitive Behavior, Conduct, and Over-Eating factors and to a lesser extent the Under-Eating factor. Poor correlations were observed between some seemingly related constructs (e.g. Avoidant Behavior factor of the ASD-CC and the Anxiety subscale of the BASC-2); however, this may be a result of the population surveyed exhibiting symptoms of psychopathology different from the typically developing population or a small sample size. ASD are a complex group of disorders characterized by heterogeneous symptom profiles (Matson & Boisjoli, 2007; Matson, Smiroldo, & Bamburg, 1998; Njardvik, Matson, & Cherry, 1999). Adding to the heterogeneity is the high rate of comorbid conditions evident in this population (Coe et al., 1999; Matson-Rush et al., 1999). In order for implementation of the least intrusive yet effective interventions, accurate diagnosis of co-occurring psychopathology is imperative (Advocate, Mayville, & Matson, 2000; Matson, 2007b; Matson & Nebel-Schwalm, 2007a). Few measures exist that have been studied with children displaying ASD, and a paucity of measures have been designed specifically to assess psychopathology in this population. Careful delineation of comorbid symptomatology in the ASD populations by researchers and clinicians is an important first step in identifying these disorders (Matson, 2007a). Further study of co-occurring mental health problems and related symptomatology is an area of much needed attention, particularly with reliable and valid measures across the broad range of developmental disabilities (Matson, LeBlanc, Weinheimer, & Cherry, 1999; Matson & NebelSchwalm, 2007b; Matson & Rivet, 2007; Matson & Wilkins, 2007; Paclawskyj, Rush, Matson, & Cherry, 1999). The ASD-CC appears to be an appropriate measure for these purposes for children with ASD. References Achenbach, T. M., Rescorla, L. A., & Maruish, M. E. (2004). The Achenbach System of Empirically Based Assessment (ASEBA) for ages 1.5–18 years The use of psychological testing for treatment planning and outcomes assessment, Vol. 2: Instruments for children and adolescents, (3rd ed.). Mahwah, NJ, US: Lawrence Erlbaum Associates Publishers. pp. 179–213. Advocate, C. D., Mayville, E. A., & Matson, J. L. (2000). 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