Behavioral problems in children with motor and intellectual disabilities: Prevalence and associations with maladaptive personality and marital relationship

Abstract

Prevalence rates of behavioral problems in children with motor disabilities are commonly based on questionnaires developed for a general population (e.g., Child Behavior CheckList). These questionnaires do not take into account lower levels of intellectual functioning. The first aim of this study was to examine the prevalence of parent-reported and daily caretaker-reported behavioral problems in children with motor and intellectual disabilities (MID) using the Developmental Behavior Checklist. Second, we investigated whether behavioral problems were related to sex and age. Our third and fourth aim were to determine whether behavioral problems are related to maladaptive personality traits and to marital stress and conflict. Participants were 101 Flemish children with MID (mean age = 14 years 6 months). For total behavioral problems, we found prevalence rates of 18% and 8% based on parent and daily caretaker reports, respectively. Based on parent reports, twenty seven percent of the children with MID exhibited anxiety problems. Behavioral problems were not related to sex. Older children showed fewer behavioral problems than younger children. Multiple hierarchical regression analyses revealed that lower scores on Compulsivity and higher scores on Emotional Instability and Disagreeableness were related to behavioral problems. In addition to personality traits, stress and conflict in the marital relationship was also positively associated with behavioral problems. Given the importance of behavioral problems in children with MID, this study is of theoretical and clinical interest and has the potential to inform targeted clinical interventions.

Introduction

Despite the fact that behavioral problems are often reported in children and adolescents (here referred to as children) with motor disabilities, few studies have empirically examined their prevalence (Colver, 2010). These studies reveal that prevalence estimates of behavioral problems are higher for children with motor disabilities in comparison with prevalence estimates for children in representative community samples (30% vs. 15%; Sniekers, Grietens, & Maes, 2002). Brossard-Racine et al. (2012) reported in a recent study a prevalence of 28% among 76 school-aged children with Cerebral Palsy. In another study of preschool children with Cerebral Palsy, the parent-reported and teacher-reported prevalence estimates were even higher, 48% and 65%, respectively (Sigurdardottir et al., 2010). However, the use of questionnaires developed for a general population – e.g., Child Behavior Checklist (CBCL; Achenbach, 1991) and Strengths and Difficulties Questionnaire (SDQ; Goodman, 1999) – is an important limitation of most of these investigations. Delays in motor development are often accompanied by delays in cognitive development (Rosenbaum et al., 2007), which in turn often lead to a lower level of intellectual functioning. Some behavioral patterns related to lower levels of intellectual functioning (such as ‘eating non-food’, ‘making non-speech noises’ and ‘echolalia’) are not included in questionnaires such as the CBCL (Einfeld & Tonge, 1995). These questionnaires are developed for general populations in which some behaviors presume a certain level of intellectual functioning (Aman, 1991). The CBCL, for instance, is less applicable for children with a moderate, severe or profound intellectual disability (Koskentausta, Iivanainen, & Almqvist, 2004). For this reason, the use of an instrument that covers more specific behavioral patterns, allows for a more accurate assessment of behavioral problems in children with motor and intellectual disabilities (MID). Hence, the first aim of this study was to estimate the prevalence rate of behavioral problems in children with MID. The second aim was to investigate whether parent-reported behavioral problems were related to child sex and age.

Etiological models have emphasized that risk factors within the child (such as personality) and in the proximal environment (such as marital conflicts) are associated with behavioral problems (Sameroff, 1995). However, associations among these risk factors and behavioral problems in children with MID are still understudied (Colver, 2010). During the last decade, there has been growing interest in the relationship between personality characteristics and behavioral problems (Tackett, 2006). Personality refers to individual differences in the tendency to behave, think and feel in certain consistent ways across different situations (Widiger, 2011). Scholars have reached increasing consensus on the structure by which the myriad of more specific personality traits can be arranged and the most widespread support has been obtained for the Five-Factor Model (FFM) or Big Five (Caspi & Shiner, 2006). The Big Five dimensions have traditionally been labeled as Extraversion, Agreeableness, Conscientiousness, Neuroticism (or Emotional Instability) and Openness (Costa & McCrae, 1992). Research has indicated that both adaptive and maladaptive personality traits are related to behavioral problems in community based populations of children and adolescents (see e.g., De Clercq et al., 2006, Nigg, 2006). Based on the vulnerability model, several studies have shown that personality traits are important precursors for the development of behavioral problems in children and adolescents or psychopathology in adulthood (Shiner and Caspi, 2003, Widiger, 2011). However, to the best of our knowledge, no studies have examined the association between maladaptive personality traits and problem behavior in a sample of children with MID. Therefore, a third aim of this study was to investigate the relationship between maladaptive personality traits and behavioral problems.

An important factor in the proximal environment related to behavioral problems is stress and conflict in the marital relationship. Several studies have reported that in a normal population, higher levels of stress and conflict in the marital relationship are associated with children's behavioral problems (Amato and Keith, 1991, Cowan and Cowan, 2002, Jenkins et al., 2005). O’Leary and Vidair (2005) have shown that marital stress and conflict are related to behavioral problems through dysfunctional parenting. However, marital stress and conflict have not yet been investigated as risk factors for behavioral problems in children with MID. Hence, a fourth aim of this study was to examine the association between marital stress and conflict and behavioral problems.

Several studies have investigated behavioral problems in children with motor disabilities using questionnaires developed for representative community samples. Prevalence estimates vary from 21% to 65% (e.g., Sigurdardottir et al., 2010). This wide prevalence range may be accounted for by different psychometric characteristics of the different instruments or differences in the definition of behavior problems (e.g., use of the borderline or clinical range). Studies using the CBCL reported prevalence rates ranged from 21% (Hendriks, De Moor, Oud, Franken, & Savelberg, 2001), 24% (Peters, Huisman, & Van Emmerik-Levelt, 1999), 30% (Sniekers et al., 2002) to 65% (Sigurdardottir et al., 2010). Using the SDQ, prevalence rates among children with Cerebral Palsy ranged from 26% to 40% (Brossard-Racine et al., 2012, Parkes et al., 2008). Accordingly, the types of behavioral problems in children with motor disabilities also varied. The most reported problems are anxiety (Hendriks et al., 2001, Van Handel et al., 2010), attention problems (Peters et al., 1999, Sigurdardottir et al., 2010), social problems (Hinton, Nereo, Fee, & Cyrulnik, 2006) and hyperactivity (Brossard-Racine et al., 2012, McDermott et al., 1996, Parkes et al., 2008). However, the use of different questionnaires hampers the comparability of studies addressing the prevalence of different types of problem behavior. Therefore, our first aim was to estimate parent-reported and daily caretaker-reported prevalence rates of behavioral problems in children with MID using the Dutch translation (Koot & Dekker, 2001) of the Developmental Behavior Checklist (DBC; Einfeld & Tonge, 1992). This instrument is developed for children with intellectual disabilities.

Past research in behavioral problems of children with motor disabilities relied largely on parent reports (e.g., Brossard-Racine et al., 2012, Parkes et al., 2008) and to a lesser extent on teacher reports (e.g., Sigurdardottir et al., 2010). Community-based studies have revealed that parents report higher prevalence rates of behavioral problems than teachers (e.g., Grietens et al., 2004). However, Sigurdardottir et al. (2010) found that teachers reported higher prevalence rate of behavior problems for children with Cerebral Palsy. In this study, we extended past research by including daily caretakers, in addition to parents, as informants. Several authors have recommended a multiple informant approach because different informants add different but legitimate and unique information about child functioning (Bartels et al., 2003, Grietens et al., 2004). Informants differ not only in the way they interpret behavior but also in the type of interactions they have with children. An important advantage of the inclusion of daily caretakers is that they are familiar with a broader range of children and they have greater expertise regarding normal and abnormal child development than parents (Grietens et al., 2004, Saudino et al., 2005). Furthermore, daily caretakers are valuable informants because some behavioral problems are primarily exhibited in interactions with other children and daily caretakers are more likely to see these interactions. Hence, we investigated both the parent-reported and daily caretaker-reported prevalence rates of behavioral problems in children with MID.

With regard to risk factors within the child, previous research has reported mixed results about the associations between behavioral problems and sex or age. For example, some studies found that boys exhibited more behavioral problems than girls (e.g., Sniekers et al., 2002), whereas others (e.g., Sipal, Schuengel, Voorman, Van Eck, & Becher, 2010) found no differences between boys and girls. With regard to age, Sipal et al. (2010) reported lower prevalence estimates for older children with Cerebral Palsy. In contrast, other investigations revealed that age was not related to behavioral problems (e.g., Parkes et al., 2008). Because of these inconsistencies in the literature, the second aim was to investigate whether behavioral problems in children with MID are related to sex and age.

There is growing consensus that the FFM is best suited to capture adaptive or normal differences in personality (Clercq, De Fruyt, & Widiger, 2009). From a dimensional perspective, it is suggested that personality traits can be described along a continuum (De Clercq et al., 2006, Widiger, 2011). In this perspective personality disorders and maladaptive personality traits are seen as extreme variants of normal personality traits (Widiger & Mullins-Sweatt, 2009). In addition, there is a growing agreement that both adaptive and maladaptive personality traits can be measured from early childhood on (Shiner and Caspi, 2003, De Clercq et al., 2009). The importance of a dimensional classification of personality is emphasized by work groups preparing the future Diagnostic and Statistical Manual of Mental Disorders-Fifth edition (DSM-V) (Widiger & Mullins-Sweatt, 2009). In line with the dimensional perspective, De Clercq, De Fruyt, and Mervielde (2003) developed the Dimensional Personality Symptom Item Pool (DIPSI), a four-factor maladaptive personality questionnaire for children and adolescents. This questionnaire measures Introversion, Disagreeableness, Compulsivity and Emotional Instability. A maladaptive trait variant of Openness was not developed because this factor is generally not included in measures for adult personality pathology (see De Clercq et al., 2006, p. 4).

One theoretical model proposed for the study between personality and behavioral problems is the vulnerability model (see e.g., Nigg, 2006, Tackett, 2006). According to this model, maladaptive personality traits are hypothesized as predisposing factors for the onset of behavioral problems (De Clercq et al., 2009, Widiger, 2011). However, previous research has mainly focused on the associations between behavioral problems and measures of adaptive personality traits. For example, research in representative community samples has identified consistent relationships between low Conscientiousness, low Agreeableness, high Extraversion and to a lesser extent high Neuroticism (Prinzie et al., 2003, Prinzie et al., 2010, Tackett, 2006, Van Leeuwen et al., 2004) and behavioral problems. Given the importance of personality in the forthcoming DSM-V (Widiger, 2011, Widiger and Mullins-Sweatt, 2009) and the fact that maladaptive personality traits have not yet been studied in children with MID, the third aim of this study was to investigate the association of behavioral problems with maladaptive personality traits.

An important risk factor in the proximal environment of the child that has been related to behavioral problems is conflict in the marital relationship (e.g., Cowan & Cowan, 2002). The family conflict perspective states that children's adjustment and well-being is negatively influenced by higher levels of interparental conflict and stress (Amato & Keith, 1991). According to Jenkins et al. (2005) and Cowan and Cowan (2002) interparental conflicts are related to behavioral problems. In particular, stress and conflict regarding child rearing practices have shown to be important risk factors for behavioral problems in children (Jenkins et al., 2005, O’Leary and Vidair, 2005). Therefore, the fourth aim of this study was to investigate whether behavioral problems were related to stress and conflict in the marital relationship.

In summary, the first aim of this study was to estimate prevalence rates of behavioral problems in children with MID using the DBC. Because this study is the first to use the DBC in children with MID, analyses regarding prevalence rates were exploratory. Based on the literature on prevalence rates in representative community samples (Grietens et al., 2004), we hypothesized that parents would report more behavioral problems than daily caretakers. Second, we aimed to investigate the associations of behavioral problems with sex and age. Given inconsistencies in the literature, analyses with regard to sex and age were also exploratory. A third aim was to examine of the association between behavioral problems and maladaptive personality traits. Based on the literature on personality traits in normal populations and in line with the vulnerability model, we hypothesized that low scores on Compulsivity, high scores on Emotional Instability and high scores on Disagreeableness would be related to behavioral problems (Prinzie et al., 2003, Prinzie et al., 2010, Tackett, 2006, Van Leeuwen et al., 2004). Fourth, we aimed to investigate the relationship between behavioral problems and marital stress and conflict. From the family conflict perspective (Amato & Keith, 1991), we hypothesized that in addition to maladaptive personality, higher scores on stress and conflict in the marital relationship would be associated with more behavioral problems (e.g., Cowan and Cowan, 2002, Jenkins et al., 2005).