The stereotyped behavior scale: psychometric properties and norms
Introduction
Stereotyped behaviors are invariant motor behaviors, ritualistic movements, peculiar postures, or unusual vocalizations or sounds that are not symptoms of neurological disorders such as Huntington’s chorea, Tourette’s syndrome, or tardive dyskinesia. The DSM-IV (American Psychiatric Association, 1994) distinguishes between stereotyped movement disorders with and those without self-injurious effects. Benign forms of stereotyped behaviors occur in typically developing children Thelen 1981, Troster 1994 and in adults without disabilities such as college students (Rafaeli-Mor, Foster & Berkson, 1999) without creating much concern. They occur more prominently in people with disabilities such as visual impairment (Tröster, Brambring & Beelman, 1991), hearing impairment (Bachara & Phelan, 1980), autism (Wing & Gould, 1979), or mental retardation (Rojahn, Tassé & Morin, 1998). This paper deals primarily with stereotyped behavior in people with mental retardation.
Prevalence estimates of stereotyped behavior in mental retardation vary, depending on the specific survey methodology. For example, two large population-based surveys each showed a prevalence rate of 0.07 (7:100) (Rojahn, Borthwick-Duffy & Jacobson, 1993). The first survey was conducted in California (n = 98,419), and the second one in New York (n = 45,683). Prevalence rates are much higher in certain subpopulations, such as 0.34 (34:100) found in residents of an intermediate care facility for people with profound mental retardation (Dura, Mulick & Rasnake, 1987). Stereotyped behavior is often treated not only for its stigmatizing effects (Jones, Wint & Ellis, 1990), but also because it is considered by some as a potential precursor of self-injurious behavior (Schroeder, Rojahn, Mulick & Schroeder, 1990), because it interferes with learning (Koegel & Covert, 1972), and because it impedes other appropriate behavior as well (Epstein, Doke, Sajwaj, Sorrell & Rimmer, 1974). Despite all we have learned about stereotyped behavior over the last few decades, we still do not know why it occurs in people with mental retardation, nor do we fully understand its origins and mechanisms.
The assessment of stereotyped behaviors is important for clinical reasons and for research purposes. While individual treatment evaluation often relies on observational techniques, group outcome studies and survey research require standardized behavior rating scales with carefully chosen items. This situation is particularly challenging with stereotypies as they are typically highly idiosyncratic and are, therefore, difficult to capture objectively in generic terms.
Several assessment tools for stereotyped behavior have been developed by researchers, with varying degrees of psychometric quality, length and utility. Some of these scales were primarily based on clinical experience lacking in proper scale development procedures (e.g., Timed Stereotypies Rating Scale by Campbell (1985), the Stereotypy Checklist by Bodfish et al. (1995), the Real Life Rating Scale for Autism [RLRSA] by Freeman, Ritvo, Yokota and Ritvo (1986), or the Behavior Problems Inventory [BPI] Rojahn 1986, Rojahn 1992. Other instruments have been developed using technically more rigorous procedures that include explicit item sampling strategies and factor-analyses (e.g., Aberrant Behavior Checklist-Residential [ABC-R] by Aman et al. (1985), the Behavior Disturbance Scale-2 [BDS-2] by Leudar, Fraser and Jeeves (1984), the Diagnostic Assessment for the Severely Handicapped [DASH-I] by Matson, Gardner, Coe and Sovner (1991), or the Nisonger Child Behavior Rating Form [NCBRF] by Aman, Tassé, Rojahn and Hammer (1996). Both kinds of instruments have strengths and weaknesses as far as research that specifically focuses on stereotyped behavior is concerned. Informally developed stereotypy instruments usually have a larger number of stereotypy items, but lack a known factor structure. The more carefully constructed instruments, on the other hand, are usually designed to assess a much wider spectrum of behavior disorders than just stereotypies, and therefore typically contain only very few stereotypy items.
Recently, two assessment instruments appeared in the literature that focused on stereotyped behaviors exclusively, that were also based on factor analytic data reduction methods and systematic item selection procedures. Berkson, Gutermuth and Baranek (1995) compiled 54 common repetitive phenomena such as body rocking and twiddling, atypical motivational patterns, rituals, sensory defensiveness, and savant skills. Factor analysis revealed seven factors. The authors noted nonetheless that a general stereotypy factor common to all the behaviors existed as well. It should be mentioned that Berkson et al.’s (Berkson et al. 1995) checklist was not intended as a clinical assessment instrument and should, therefore, not be used as such at this point. More recently, the Stereotyped Behavior Scale (SBS) was published (Rojahn et al., 1997). This empirically developed assessment instrument for adolescents and adults with mental retardation, originally consisted of 26 items that were scored on six-point frequency scales. At the beginning of the item sampling process, more than 120 stereotyped behavior descriptors were gathered from behavior rating scales such as the ABC-R (Aman et al., 1985), the BDS-2 (Leudar et al., 1984), the DASH-1 (Matson et al., 1991), the RLRSA (Freeman et al., 1986), the Problem Behavior Inventory (Willis & LaVigna, 1989), and the BPI (Rojahn, 1986, 1992). LaGrow and Repp’s (LaGrow and Repp, 1984) compilation of stereotyped behaviors derived from a comprehensive review of the treatment literature was also explored as a source of items. After eliminating obvious semantic redundancies, 66 items remained in the pool. Service provider staff in three states completed the preliminary 66-item scale for 599 clients known for stereotypic behaviors. Items with test-retest reliability below r = .45 and/or interrater agreement below r = .30 were dropped. The remaining 30 items were subjected to a principle component analysis with varimax rotation. A single-factor solution was adopted, which explained 24.9% of the variance. After eliminating four items with low factor loadings, the resulting 26-item version had an internal consistency α of 0.88, an intraclass correlation coefficient (ICC) test-retest reliability of 0.82, and an interrater reliability of 0.33. It was concluded that internal consistency and test-retest reliability of the SBS were acceptable to good, but the authors were concerned about the low interrater agreement. In addition, determining the validity of the scale seemed necessary.
Therefore, a psychometric study to examine further the test-retest reliability, interrater reliability, internal consistency, and validity of the SBS seemed warranted. However, before this study, the SBS was slightly modified. The item “Suddenly runs” was deleted because it was semantically almost identical with the item “Has bursts of running around.” Moreover, these items correlated highly with one another (Spearman ρ = 0.76; n = 599). It was also decided to eliminate the item “Has pill rolling motions,” because this behavior is usually associated with extrapyramidal effects following the use of neuroleptics rather than with stereotyped behavior. Thus, the new SBS version consists of 24 items.
Section snippets
Participants
Participants were 45 adult residents from a medium-sized public institution in the Midwest with approximately 120 residents. The chief psychologist, who had worked at that institution for more than four years and who was familiar with his clients’ behaviors, recruited the participants. His task was to select a total of 45 individuals and to classify them into three a priori groups: A group with no or very mild and/or infrequent stereotypy, a group with moderately intense and/or frequent forms
Method
To obtain normative data for the SBS, we reanalyzed the data from the first SBS study (Rojahn et al., 1997). We will describe only those study features that are relevant for the normative data here.
Psychometric study
The psychometric SBS study was conducted with residents from a center for people with mental retardation. The chief psychologist of the center assembled three subgroups according to the frequency of occurrence and intensity of stereotyped behavior. As far as chronological age, gender, presence of psychiatric diagnoses, and prescription of psychotropic medication was concerned, the three groups were very comparable. As one would expect from epidemiologic findings (e.g., Rojahn et al., 1993), the
Acknowledgements
This study was supported in part by a grant awarded to the Nisonger Center for Mental Retardation and Developmental Disabilities, a University Affiliated Program at The Ohio State University, from the U.S. Department of Health and Human Services, Administration on Developmental Disabilities (grant # 07DD0270/16).
References (34)
- et al.
The Nisonger CBRFA child behavior rating form for children with developmental disabilities
Research in Developmental Disabilities
(1996) - et al.
A scale for rating symptoms of patients with the syndrome of Autism in real life settings
American Academy of Child Psychiatry
(1986) - et al.
The Aberrant Behavior ChecklistA behavior rating scale for the assessment of treatment effects
American Journal of Mental Deficiency
(1985) - American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders, fourth edition....
- et al.
Rhythmic movement in deaf children
Perceptual and Motor Skills
(1980) Generalizability of behavioral observationsA clarification of interobserver agreement and interobserver reliability
American Journal of Mental Deficiency
(1979)- et al.
Relative prevalence and relations among stereotyped and similar behaviors
American Journal on Mental Retardation
(1995) - et al.
Compulsions in adults with mental retardationPrevalence, phenomenology, and comorbidity with stereotypy and self-injury
American Journal on Mental Retardation
(1995) Timed Stereotyped Behavior Scale
Psychopharmacology Bulletin
(1985)Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology
Psychological Assessment
(1994)
Prevalence of stereotypy among institutionalized nonambulatory profoundly mentally retarded people
American Journal on Mental Deficiency
Generality and side effects of overcorrection
Journal of Applied Behavior Analysis
Gilliam Autism Rating Scale
Composite versus multiple-rating scales in the assessment of psychopathology in people with mental retardation
Journal of Intellectual Disability Research
The social effects of stereotyped behaviour
Journal of Mental Deficiency Research
The relationship of self-stimulation to learning in autistic children
Journal of Applied Behavior Analysis
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