Gender effects on challenging behaviors in children with autism spectrum disorders

Challenging behaviors are extremely prevalent within the autism spectrum disorder (ASD) population. To date, numerous factors affecting the rates of challenging behaviors within the ASD population have been examined including age, gender, ethnicity, and intellectual functioning. Controversy has arisen in regard to the effect of gender on challenging behaviors rates in individuals with ASD with some researchers finding differences while others do not. The aim of the current study was to examine the gender effects of children and adolescents with ASD on challenging behavior rates in an effort to assist in clarifying this relationship. Three hundred ninety-one children ages 2 through 17 years participated in the current study and were assigned to one of four groups: male with ASD, male without ASD, female with ASD, and female without ASD. Differences in rates of challenging behaviors between the groups were examined using the Autism Spectrum Disorder-Behavior Problems for Children. Overall, gender was not found to have an effect on the rates of challenging behaviors among children and adolescents with or without ASD. The implications of this finding are discussed along with possible future avenues of investigation.     

Assessing challenging behaviors in children with autism spectrum disorders: a review

A common covarying group of behaviors with ASD are self-injury, aggression, noncompliance, and stereotypies. These problems and related challenging behaviors are problematic in that they are physically dangerous and can impede learning and access to normal activities. Additionally, they require a considerable amount of resources, and compound the difficulty in treating core ASD symptoms. Despite the high profile challenging behaviors present in this population, there has not been a great deal of research regarding assessment, identification, and monitoring of such difficulties. This review covers available empirical based methods for assessing these behaviors. A discussion is provided of potential avenues for future research and clinical practice which is urgently needed for ASD children at this time.     

Cross cultural differences in challenging behaviors of children with autism spectrum disorders: An international examination between Israel, South Korea, the United Kingdom, and the United States of America

Challenging behaviors are deemed extremely common within the autism spectrum disorders (ASD) population. Numerous factors and their effects upon the presence and severity of challenging behaviors within this population have been investigated. However, there has been limited research to investigate the effects of cultural differences on challenging behaviors. The aim of the current study was to examine differences between cultures in the reported presence and severity of a multitude of challenging behaviors commonly displayed by children with ASD. The Autism Spectrum Disorders-Behavior Problems for Children was used to assess possible differences between the United States and three other countries (South Korea, Israel, and the United Kingdom). Relatively few differences were found between the United States and both South Korea and Israel, with the United States endorsing a higher presence and severity on items that differed. In contrast, the United States and the United Kingdom differed on nearly half of the behavior items assessed with the United Kingdom reporting greater endorsements. The potential implications of these results are discussed.     

Challenging behaviors in toddlers diagnosed with autism spectrum disorders with the DSM-IV-TR and the proposed DSM-5 criteria

With publication of the DSM-5 slated for May 2013, it has been predicted that the new diagnostic criteria will cause a decrease in the prevalence of autism spectrum disorders (ASDs), seriously impacting children no longer meeting criteria for the disorder. A majority of individuals with ASD have behavior problems which are not considered core features of the disorder but are significantly impairing and often the focus of intervention. The aim of the current study was to investigate types of challenging behaviors in toddlers who may no longer meet diagnostic criteria for ASD using a psychometrically sound measure, the Baby and Infant Screen for Children with aUtIsm Traits (BISCUIT) – Part 3. The study included 3339 toddlers, 501 who will retain ASD diagnosis according to the DSM-5; 439 who will no longer meet criteria, and a comparison group of 2399 toddlers referred for evaluation due to atypical development. Though toddlers diagnosed under the DSM-5 exhibited the most challenging behaviors, those who did not meet DSM-5 criteria exhibited significantly more challenging behaviors than the atypically developing toddlers. The effect of the changes in ASD diagnostic criteria on access to early behavioral interventions warrants careful consideration as the new DSM-5 criteria are adopted.     

Sleep, anxiety and challenging behaviour in children with intellectual disability and/or autism spectrum disorder

Children with an intellectual disability (ID) and/or autism spectrum disorder (ASD) are known to suffer from significantly more sleep problems, anxiety and challenging behaviour (CB) than typically developing children (TD), yet little is known about the relationship between these factors in the child ID/ASD population. The study aim was to examine these relationships. We hypothesised that there would be significant positive correlations between the three factors and that sleep problems and anxiety would predict a significant amount of the variance in levels of CB. Parental measures of sleep problems, anxiety and CB were completed by 187 parents of children with ID and/or ASD. Significant positive associations were found between the three factors. A hierarchical multiple regression showed that medication, sleep problems and anxiety accounted for 42% of the variance in CB, with a large effect size. These findings suggest that these relationships should be considered during clinical practice, particularly in the case of CB interventions where sleep problems and/or anxiety are also present.     

The relationship between race and comorbid symptoms in infants and toddlers with autism spectrum disorder

Researchers have indicated that persons with autism spectrum disorder (ASD) population evince higher rates of comorbid symptoms. While the relationship between comorbid symptoms and factors such as autism symptom severity, IQ level, age, communication abilities, and degree of social impairment were previously examined, there has been limited research on the effect of race in this area. The current study examined the potential role of race in comorbid symptoms in toddlers with ASD and atypically developing toddlers without a diagnosis of ASD using The Baby and Infant Screen for Children with aUtIsm Traits – Part 2 (BISCUIT-Part 2). Based on the current findings, African-American toddlers evinced higher rates of comorbid symptoms than Caucasian toddlers and toddlers of other races. In addition, toddlers with ASD evinced higher rates of comorbid symptoms than atypically developing toddlers without a diagnosis of ASD. Implications regarding these findings are discussed.     

The effect of cognitive skills and autism spectrum disorder on stereotyped behaviors in infants and toddlers

Stereotyped behaviors are prominent in both the ASD and ID populations; stereotypies can impede social skill acquisition, interfere with learning, and adversely affect an individual's quality of life. The current study explored the effect of cognitive skills and autism spectrum disorder (ASD) on the rate of stereotypies in 2019 children aged 17–39 months. Cognitive abilities were assessed using the cognitive developmental quotient (DQ) on the Battelle Developmental Inventory, Second Edition (BDI-2); two levels of cognitive skill were used: (1) low (cognitive DQ less than or equal to 70), and (2) typical (cognitive DQ greater than 70). Stereotypies were examined utilizing the Baby and Infant Screen for Children with aUtIsm Traits, Part 3 (BISCUIT-Part 3). Children with ASD were found to have greater rates of overall stereotyped behaviors compared to children with atypical development, regardless of cognitive level; however, children with ASD and typical cognitive ability evinced the highest rate of stereotypies. An examination of specific stereotyped behaviors (i.e., unusual play with objects, repeated and unusual vocalizations, repeated and unusual body movements) revealed disparate results. Research and clinical implications regarding these findings are discussed.     

Reduced anxiety following pivotal response treatment in young children with autism spectrum disorder

Up to 40% of children with Autism Spectrum Disorder (ASD) exhibit co-occurring anxiety symptoms. Despite recent success in mitigating anxiety symptoms in school-aged children with ASD (mean age >9 years) using adapted versions of Cognitive Behavioural Therapy, little is known about potential treatment outcomes for younger children. To address the gap in the literature, this open-label study evaluated change in anxiety following a 16-week open-label trial of Pivotal Response Treatment (PRT) in children with ASD aged 4–8 years. PRT is a behavioural treatment based on the principles of Applied Behaviour Analysis and has a primary aim of increasing social communication skills in children with ASD through natural reinforcements. To minimise conflation of anxiety and other co-occurring symptoms such as disruptive behaviour and attention-deficit hyperactivity disorder, we measured anxiety using the autism anxiety subscale of the Child and Adolescent Symptom Inventory (CASI) devised by Sukhodolsky et al. (2008). We observed significant anxiety reduction over 16-weeks of PRT. Furthermore, anxiety reduction was independent of changes in autism symptom severity. This study shows promising results for PRT as an intervention for reducing anxiety in young children with ASD.     

Salivary cortisol levels and challenging behavior in children with autism spectrum disorder

A relationship between stress and challenging behavior in individuals with autism spectrum disorder (ASD) has been theorized but infrequently examined empirically. The current study sought to examine the relationship between a parent-reported measure of stress, a physiological measure of stress (diurnal salivary cortisol), and various topographies of challenging behavior among 61 children and adolescents diagnosed with ASD between the ages of three and 18 years. Significant differences in cortisol levels between those engaging in high and low rates of stereotyped behavior were observed such that higher levels of stereotypy appeared an overt manifestation of higher levels of stress. A comparison between a subset of participants with ASD and typically developing peers matched on age, gender, and pubertal status failed to yield any differences in diurnal cortisol levels or cortisol variability between the two groups. The results of the current study suggest that similar levels of stress may exist among children with autism and their typically developing peers, but that for a subset of individuals with ASD, stereotyped behavior may be an indicator of elevated cortisol levels.     

Characterizing difficulties with emotion regulation in toddlers with autism spectrum disorder

BackgroundDifficulties with emotion regulation (ER) underlie emotional/behavioral challenges and co-occurring psychiatric symptoms in autism spectrum disorder (ASD), yet very little is known about the early development of emotion dysregulation. The present study aimed to identify differences in positive and negative emotional reactivity and regulation strategies in toddlers with and without ASD.MethodNine tasks from the Laboratory Temperament Assessment Battery (Lab-TAB) were completed with 37 toddlers with and without ASD (22–28 months). Video-recordings of these tasks were coded by research assistants using a behavioral coding scheme tapping facial, bodily, and vocal affect and the frequency of ER strategies. Mixed model analyses were performed to examine the mean affect and total regulation strategies across each task and t-tests were conducted to assess the types of ER strategies utilized.ResultsToddlers with ASD showed significantly less positive affect and greater frustration compared to non-ASD toddlers; reactivity was comparable between the groups for fear. Both groups used ER strategies in a similar pattern across tasks, with the exception that toddlers with ASD more often engaged in distraction to regulate. Effects of age and developmental level are discussed.ConclusionsToddlers with ASD were robustly characterized by greater frustration and lower joy despite frequent and age appropriate attempts to regulate their emotions. This study provides preliminary evidence that observable indicators of emotion dysregulation are present by two years of age. Clinical implications and future research directions are discussed.     

The relationship between gender and age of first concern in toddlers with autism spectrum disorders

The age at which parents first developed concerns over their child's development was examined in 965 toddlers with autism spectrum disorders (ASD) and atypical development to examine the potential role of gender. A two-way analysis of covariance was conducted with gender and diagnosis entered as independent variables, age at assessment entered as a covariate, and age of parents’ first concerns entered as the dependent variable. The average age of parents’ first concerns was significantly younger for females when compared to males. Additionally, the age of parents’ first concerns was significantly younger for toddlers with ASD when compared to toddlers with atypical development. No significant interaction was found. Possible explanations for the results and their implications are discussed.     

Response to second generation antipsychotics in youth with comorbid bipolar disorder and autism spectrum disorder

Objective: To assess the impact of comorbid autism spectrum disorders (ASD) on the response to second‐generation antipsychotics (SGA) in pediatric bipolar disorder (BPD). Methods: Secondary analysis of identically designed 8‐week open‐label trials of SGA monotherapy (risperidone, olanzapine, quetiapine, ziprasidone, or aripiprazole) in youth with BPD. Results: Of the 151 BPD subjects 15% (n= 23) met criteria for comorbid ASD. There were no differences in the rate of antimanic response (YMRS change ≥30% or CGI‐Improvement ≤2: 65% vs. 69%; P= 0.7) in the presence of comorbid ASD. Conclusion: No difference observed in the rate of antimanic response or tolerability to SGA monotherapy in the presence of ASD comorbidity.     

Using the Prevent-Teach-Reinforce model to reduce challenging behaviors in children with autism spectrum disorder in home settings: A feasibility study

BackgroundChildren with autism spectrum disorders (ASD) often engage in high levels of challenging behaviors, which can be difficult to reduce for parents in home settings. The purpose of our study was to address this issue by examining the effects of adapting the Prevent-Teach-Reinforce model (PTR) to support parents in reducing challenging behaviors in children with ASD in a feasibility study.MethodWe conducted a non-blinded randomized trial to compare the effect of the PTR to a business as usual, less intensive intervention (i.e., 3-hr training) on challenging and desirable behaviors (N = 24).ResultsThe PTR and the 3-hr parental training both reduced challenging behaviors and increased desirable behaviors. Moreover, parents implemented the PTR model with high fidelity and rated it highly for social acceptability.ConclusionsThis feasibility study showed that it is possible to compare the PTR with families to a less intensive intervention in a future trial. However, research with a larger sample is essential to determine whether the PTR is more effective than less intensive treatments (e.g., parent training).     

Relations among restricted and repetitive behaviors,anxiety and sensory features in children with autism spectrum disorders

The purpose of this study was to explore how atypical reactions to sensory stimuli contribute to the relation between restricted and repetitive behaviors and anxiety in children with autism spectrum disorders (ASD). In Study 1, factor analysis of restricted and repetitive behaviors was carried out using the Repetitive Behavior Questionnaire-2 (RBQ-2), completed by 120 parents of 2- to 17-year-olds with ASD. Two subtypes resulted: repetitive sensory and motor behaviors, and insistence on sameness, accounting for 40% of the variance. This two-factor solution was retained even when the sensory items of the RBQ-2 were removed. In Study 2, 49 of the same parents also completed the Spence Anxiety Scales and the Sensory Profile. The insistence on sameness factor was significantly associated with anxiety while the repetitive motor behaviors factor was not. The relation between anxiety and insistence on sameness was mediated by sensory avoiding and to a lesser extent by sensory sensitivity. Implications for arousal explanations of ASD and for clinical practice are discussed.     

Anxiety and avoidance in infants and toddlers with autism spectrum disorders: Evidence for differing symptom severity and presentation

Little is known about the symptoms of anxiety in very young children with autism spectrum disorders, particularly comparisons between Autistic Disorder (AD) and Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS). In the current study, toddlers (i.e., 17–37 months of age) with diagnoses of either AD (N = 159) or PDD-NOS (N = 154) were compared to atypically developing toddlers who did not meet criteria for an autism spectrum disorder (N = 200). Results indicated an overall pattern whereby toddlers with AD had more severe anxious and avoidant symptoms than either toddlers with PDD-NOS or controls. Further, toddlers with PDD-NOS were significantly more severe than controls. Additional analyses examining specific differences between the groups on anxious and avoidant items were conducted as well. Overall, toddlers with AD appear to have more severe anxiety than either those with PDD-NOS or controls, who did not differ on many items.     

Emerging cognitive profiles in high-risk infants with and without autism spectrum disorder

This paper examined early developmental trajectories in a large, longitudinal sample at high-risk for ASD (‘HR’) and low-risk (‘LR’) controls, and the association of trajectories with 3-year diagnosis. Developmental assessments were conducted at 6, 12, 24 months, and 3 years, with blinded “clinical best-estimate” expert diagnosis at age 3. HR infants were enrolled based only on familial risk. LR infants, from community sources, had no first- or second-degree ASD relatives. All infants were born at 36–42 weeks, weighing ≥2500 g, with no identifiable neurological, genetic, or severe sensory/motor disorders. Analytic phase I: semi-parametric group-based modeling to identify distinct developmental trajectories (n = 680; 487 HR; 193 LR); phase II: Trajectory membership in relation to 3-year diagnosis (n = 424; 310 HR; 114 LR). Three distinct trajectories emerged (1) inclining; (2) stable-average; (3) declining; trajectory membership predicted diagnosis (χ² = 99.40; p < .001). Most ASD cases were in stable-average (50.6%) or declining trajectories (33.8%); most non-ASD-HR infants were in inclining (51.9%) or stable-average (40.3%) trajectories. The majority of LR controls were in the inclining trajectory (78.9%). Within the declining trajectory, over half had ASD (57.8%), but 40% were non-ASD-HR infants. Declining/plateauing raw scores were associated with, but not exclusive to, ASD. Findings underscore the importance of monitoring the emergence of ASD symptoms and overall development in high-risk children. Evidence of developmental slowing or decline may be associated not only with ASD, but with other suboptimal outcomes, warranting careful clinical follow-up.     

Caregiver-mediated approaches to managing challenging behaviors in children with autism spectrum disorder

A significant proportion of children with autism spectrum disorder (ASD) are referred to mental health centers due to the presence of challenging behaviors. Because challenging behaviors in children and adolescents with ASD often result from underlying social and communication difficulties and comorbid anxiety, traditional caregiver-mediated behavior intervention techniques developed for children with disruptive behavior disorders may need to be adapted for this population. Behavioral interventions that target communication skills, social skills, anxiety, and sensory responsiveness in children with ASD may be needed. Notably, while best practice necessitates the involvement of caregivers in treating children and adolescents with ASD, few randomized control studies have examined the effectiveness of caregiver-implemented interventions in reducing challenging behaviors. This review summarizes the current literature with regard to caregiver-mediated behavioral interventions for children with ASD, and suggests areas for intervention development and research.     

The impact of familial autism diagnoses on autism symptomatology in infants and toddlers

Debate regarding the etiology of Autism Spectrum Disorders (ASD) is on the rise with numerous theories being put forth. Currently, the theory with the most empirical support is the interaction of multiple genes. Many studies have provided evidence that as the incidence of ASD increases so do genetic similarities. However, very little research has focused on the presentation of ASD symptomatology in those individuals with or without ASD diagnoses who have biological relatives with or without ASD diagnoses. The aim of the current study was to first examine the percentage of toddlers with and without ASD who had biological relatives with ASD. Next, the impact familial ASD had on ASD symptomatology within infants and toddlers with and without diagnoses of ASD was investigated. In the first study, 438 toddlers with an ASD diagnosis and 1,071 who were atypically developing without an ASD diagnosis were examined. A greater percentage of toddlers with ASD were noted to have a biological relative with an identified ASD in comparison to atypically developing toddlers. In the second study, no significant differences emerged between groups dependent on familial ASD of symptoms of autism as measured by the Baby and Infant Screen for Children with aUtIsm Traits (BISCUIT). As such, despite previous research indicating a strong genetic link to ASD, this link is undoubtedly complex and not necessarily related to ASD symptomatology. Suggestions for further research are provided.     

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

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 (BDI-2). 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.     

Impact of ADHD symptoms on autism spectrum disorder symptom severity

Despite the official exclusion criteria for autism spectrum disorder (ASD) and attention deficit/hyperactivity disorder (ADHD) in the DSM-IV and ICD-10, patients with ASD often show ADHD symptoms. We aimed to examine the potential influence of ADHD symptoms on autistic psychopathology in a large sample of patients with ASD. We tested the hypothesis that patients with ASD and an additional ADHD (ASD+) would show a higher severity of autistic symptoms than those with ASD only (ASD?). We measured autistic symptoms using the autism diagnostic observation schedule (ADOS-G), the autism diagnostic interview (ADI-R), and the social responsiveness scale (SRS). To measure overall psychopathology and ADHD symptoms, we used the child behavior checklist (CBCL) and the ADHD rating scale (FBB-ADHS), respectively. Group differences between the ASD+ and the ASD? group (group division was conducted according to the results of the FBB-ADHS) were calculated using a univariate analysis of variance (ANOVA). The ASD+ group showed a greater severity of autistic symptoms than the ASD? group, measured by the SRS and the ADI-R. Especially in the social interaction subscale (ADI-R), a significantly higher symptom severity was found in the ASD+ group. No significant group differences were found regarding autistic symptoms measured by the ADOS-G. Patients with ASD and an additional ADHD expressed a stronger severity of autistic symptoms than patients with ASD only. According to our results, the possibility of a co-diagnosis of ADS and ADHD, as is being planned in the DSM-5, is in line with earlier studies, is highly reasonable, will simplify research, and have therapeutic implications.