Targeting Challenging Behaviors Exhibited by Young Children with Autism Spectrum Disorder

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8th Feb 2020 Health And Social Care Reference this

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Abstract

Challenging behaviors are form of a notable part of Autism Spectrum Disorder (ASD) symptomatology. Pertinent to the conspicuous disparity in the popularity of ASD between males and females, the purpose of this study is to compare the presence and severity of challenging behaviors between boys and girls. Hypothesis: Girls with Autism Spectrum Disorder will have more severe challenging behaviors than boys. This study will employ a quantitative comparative design to measure the prevalence and severity of challenging behaviors among diagnosed children (aged 5-10 years) with ASD. The Autism Spectrum Disorder-Behavior Problems for Children (ASD-BPC) scale will be the principal instrument of measurement of the challenging behaviors. Descriptive and inferential statistics will be used to summarize and draw conclusions from the data. The results of this study will shed light on whether, professional counselors and therapists need to use different interventions in the management of ASD in girls and boys. Furthermore, the findings will provide useful insights to parents and teachers of ASD children on the most effective coping strategies.

Targeting Challenging Behaviors Exhibited by Young Children with Autism Spectrum Disorder

Introduction

Background

Autism spectrum disorder refers to several “neurodevelopmental disorders characterized by core deficits in social interaction and communication impairments, restricted, and repetitive behaviors” (Kirkovski, Enticott& Fitzgerald, 2013). Generally, the condition affects 1 in every 50 children in the United States (Blumberg et al., 2013). The manifestation of symptoms in ASD is heterogeneous with some children having severe intellectual disability while others may have above-average level of intelligence. According to prevalence reports, ASD predominantly affects males with a male to female ratio of about 4:1 (Baio et al., 2018).

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The gender disparity in diagnosis has been contested by various researchers citing low sensitivity of assessment scales to ASD in girls (Kreiser& White, 2013). Other studies have described theories explaining the gender difference in the prevalence of ASD (Harrop et al., 2014). Yet, there is no concrete explanation of the large male: female ratio.  However, the knowledge gaps extend further than the diagnosis of ASD; a few studies have explored the differences in manifestation of symptoms among male and female children. One of the typical signs and symptoms of ASD is the presence of challenging behaviors. Challenging behaviors in ASD include self-injury, aggression, verbal tantrums and other socially inappropriate behaviors (Beighley et al., 2013). Based on the reported occurrence difference, it is important to study how ASD symptoms may vary between boys and girls.

 

Problem Statement

ASD is one of the most common developmental disorders in the United States affecting more boys than girls in the ratio of 4:1 respectively. Even though females are affected less frequently than males, girls require a greater symptom threshold for clinicians to settle for an ASD diagnosis (Harrop et al., 2015). This implies that diagnosed cases of ASD in females are more likely to present with severe symptoms. In fact, other reports indicate that the sex ratio becomes evenly distributed in moderate to severe ASD.

Challenging behaviors form a notable part of ASD symptomatology even though they are not a basis for diagnosis (Hattier, Matson, Belva&Horovitz, 2011). In fact, children with ASD are more likely to present with challenging behaviors than any other psycho-developmental conditions (Kozlowski et al., 2012). The commonly cited challenging behaviors in ASD include destruction of property, aggression or injury directed to self or peers, tantrums, among others (Beighley et al., 2013; Hattier et al., 2011). These problematic behaviors can exacerbate the core deficits evident in ASD children leading to extrapolated implications on the child’s learning and social development.

While the prevalence of challenging behaviors among ASD children has been studied by various researchers, a few studies have aimed at advancing the glaring gender difference to these behaviors. Specifically, fewer studies have compared the occurrence of challenging behaviors between boys and girls and the results of pertinent literature are not conclusive. The purpose of this study is to determine the effect of gender on the presence and severity of challenging behaviors. This research is relevant because of the potential to provide useful insights on the management of ASD thus enhancing parenting and education.

Literature Review

Findings of previous researchers comparing the presence and severity of challenging behaviors between boys and girls are inconclusive. Kozlowski et al. (2012) compared challenging behaviors among 185 children with High-Functioning Autism (HFA), Asperger’s disorder, and typical development and their multivariate analysis of variance revealed no difference on challenging behaviors between boys and girls. However, the study reported racial differences in the manifestation of problematic behaviors. In a matched boy-girl comparison, Harrop et al. (2014) noted that boys and girls with ASD are more similar than different in terms of their social communication and children involvement in play activities. Nevertheless, some challenging behaviors in ASD (such as tantrums) are indirectly related to social communication.

On the other hand, Amr et al. (2011) explored sex differences among Arab children (aged 4-11 years) with ASD and identified increased instances of challenging behaviors among effected boys. However, Amr et al. (2011) used a relatively small sample of 37 boys and 23 girls. After analysis of data from the Autism360 online database, Baker and Milivojevich (2013) replicated the findings of Amr et al. (2011) that boys have more problematic behaviors compared to girls. The Autism360 is an online database in which ASD adults as well as caregivers of autistic children anonymously describe the ASD manifestations. Baker and Milivojevich used a sample of 1495 boys and 336 girls aged 2-18 years.

While the results of these studies may be valid, Kirkovski, Enticott and Fitzgerald (2013) noted that gender differences in the manifestation of ASD may be better observed in later stages of life, indicating that studies using toddlers may be limited. As evident in the studies, toddlers form a significant part of the study samples. Another cause for concern is the male dominance in prevalence. This disparity has led to the recruitment of fewer female subjects than males. Studies using significantly fewer female subjects compared to males indicates that comparisons made thereof may be limited. In a review by Kirkovski, Enticott and Fitzgerald (2013), the reviewers observed that Murphy, Healy & Leader (2009) reported no difference on challenging behaviors between boys and girls regardless of the obvious proportionate superiority in expression of challenging behaviors in girls. As Kirkovski, Enticott and Fitzgerald (2013) cited, Murphy et al. (2009) recruited 130 ASD boys and 27 girls. The proportion of girls with challenging behaviors was at 7.4% (2 cases out of 27) while for boys it was 2.3% (3 cases out of 130 boys).

Methods

Research Question and Hypothesis

Prevalence studies on (ASD) have indicated that the prevalence of ASD varies significantly between males and females, with the boys-to-girls ratio of about 4:1 (Baker &Milivojevich, 2013). Therefore, it is important to study how ASD symptoms may vary between boys and girls. This study aims at answering the following research question: Do girls with ASD manifest more severe challenging behaviors than boys with Autism Spectrum Disorder? The proposed study will test the following hypothesis: Girls with Autism Spectrum Disorder will have more severe challenging behaviors than boys.

Participants

The target population for this study are all elementary school children (age 5-10 years) diagnosed with ASD in Alabama. The Centers for Disease Control and Prevention (CDC) reported that the population of 8-year old children with ASD as of the year 2010 was 125 (Centers for Disease Control and Prevention [CDC], 2012). This number accounted for ASD children who were 8-years old at the time of data collection. The population of ASD children could be higher as the CDC surveillance program collected data in only nine counties; Blount, Cherokee, DeKalb, Jackson, Jefferson, Madison, Marshall, Shelby, and Tuscaloosa (Centers for Disease Control and Prevention [CDC], 2012). Nevertheless, the CDC report represents the average age of focus of this study (5-10 years).

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For generalizability purposes, the sample should be derived from all the elementary schools in Alabama. However, this would not be possible because of resource constraints (time and money). Therefore, the participants will be selected from elementary schools in one county (Pike County).

This study will employ a probability sampling technique; specifically, stratified random sampling. This method is appropriate because of the well-recognized gender disparity in the prevalence of ASD. The male to female ASD ratio is about 4:1 (Baker & Milivojevich, 2013). Therefore, the accessible population will be divided into two strata based on gender, which is male and female.  Thereafter, participants will be randomly selected from the two strata; 80% of the sample from the male stratum and the other 20% from the male stratum. These sub-samples are representative of how the disorder affects the two groups. Because the participants are elementary school children, they will be recruited together with their parents or guardians. Accordingly, the sample will consist of parent-child dyads and only children whose parents give consent to participate in this study will be included.

Sample Size

The Yamane (1967) formula will be used to calculate the required size of the sample.

 

Where;      n = sample size

                  N= Total population

                  e = margin of error at CI of 95% (0.05)

Since N = 125 (Centers for Disease Control and Prevention [CDC], 2012).

          n = 125/[1+(125×0.052)]

          n= 95

Instruments

The independent variable in this study is gender while the independent variable is the manifestation of challenging behaviors. Challenging behavior is one of the common manifestations of ASD and include self-injury, aggression, verbal tantrums and other socially inappropriate behaviors (Beighley et al., 2013). The study will measure the presence and severity of the challenging behaviors using the Autism Spectrum Disorder-Behavior Problems for Children (ASD-BPC) scale (Matson, Gonzalez & Rivet, 2008). The ASD-BPC scale is one of a three-part tool used to assess for ASD symptomatology, comorbid conditions (psychiatric conditions), and challenging behaviors. The ASD-BPC has been widely utilized in the assessment of challenging behaviors and generally has high validity and reliability (Matson, Gonzalez & Rivet, 2008). The scale consists of 18 elements that assess for challenging behaviors. The parents or guardians will rate each of the 18 elements (challenging behaviors) depending on their presence and severity with 0 indicating that the challenging behavior is not a problem, 1 implying that it is a mild problem and 2 suggesting that it is a severe problem. After the scale is duly rated, the scores are summed up to get the overall score. The range of ASD – BPC is 0 – 36, with lower scores indicating the child behavior is less challenging.

Study Design

The study will employ a quantitative comparative design. According to Boswell and Cannon (2017), the comparative design is appropriate when the researcher has no intention of manipulating or controlling the independent variable with “the dependent variable being the only variable measured in two or more groups” (p. 115). This description perfectly fits with the procedures of the current study.

The study subjects will be divided into two groups of males and females. The presence and severity of the dependent variable (challenging behaviors) will be measured using the ASD-BPC scale. The total scores of all participants (the overall scores in the ASD-BPC scale) in each of the two groups will be added. Descriptive statistics will be used to summarize the data, including the mean score in each of the two groups. The investigator will then compare the means of the two groups to determine whether there is a difference in the presence and severity of challenging behaviors between the males and females. The researcher will then use inferential statistics to ascertain that the difference in the means (if any) is statistically significant, i.e. it did not arise by random chance. To achieve this degree of certainty, the analysis will employ a two-tailed t-test to determine the significance of the difference between the two means.

Audience Utilization of Possible Results

 The results of this study may be useful in advancing the meaning of the gender disparity in the prevalence of ASD. As Baker and Milivojevich (2013) noted, the meaning of the severe gender difference is limited. Importantly, the results will shed light on whether, professional counselors and therapists need to use different interventions in the management of ASD in girls and boys. Furthermore, the findings will provide useful insights to families with ASD children on the most effective coping strategies. This study will also guide teachers who are interacting with ASD children in the development of learning approaches best suited for girls with ASD. Lastly, the contributions of this research may be useful in devising effective coping mechanisms for the challenging behaviors that ASD children may manifest within the school settings.

References

Abstract

Challenging behaviors are form of a notable part of Autism Spectrum Disorder (ASD) symptomatology. Pertinent to the conspicuous disparity in the popularity of ASD between males and females, the purpose of this study is to compare the presence and severity of challenging behaviors between boys and girls. Hypothesis: Girls with Autism Spectrum Disorder will have more severe challenging behaviors than boys. This study will employ a quantitative comparative design to measure the prevalence and severity of challenging behaviors among diagnosed children (aged 5-10 years) with ASD. The Autism Spectrum Disorder-Behavior Problems for Children (ASD-BPC) scale will be the principal instrument of measurement of the challenging behaviors. Descriptive and inferential statistics will be used to summarize and draw conclusions from the data. The results of this study will shed light on whether, professional counselors and therapists need to use different interventions in the management of ASD in girls and boys. Furthermore, the findings will provide useful insights to parents and teachers of ASD children on the most effective coping strategies.

Targeting Challenging Behaviors Exhibited by Young Children with Autism Spectrum Disorder

Introduction

Background

Autism spectrum disorder refers to several “neurodevelopmental disorders characterized by core deficits in social interaction and communication impairments, restricted, and repetitive behaviors” (Kirkovski, Enticott& Fitzgerald, 2013). Generally, the condition affects 1 in every 50 children in the United States (Blumberg et al., 2013). The manifestation of symptoms in ASD is heterogeneous with some children having severe intellectual disability while others may have above-average level of intelligence. According to prevalence reports, ASD predominantly affects males with a male to female ratio of about 4:1 (Baio et al., 2018).

The gender disparity in diagnosis has been contested by various researchers citing low sensitivity of assessment scales to ASD in girls (Kreiser& White, 2013). Other studies have described theories explaining the gender difference in the prevalence of ASD (Harrop et al., 2014). Yet, there is no concrete explanation of the large male: female ratio.  However, the knowledge gaps extend further than the diagnosis of ASD; a few studies have explored the differences in manifestation of symptoms among male and female children. One of the typical signs and symptoms of ASD is the presence of challenging behaviors. Challenging behaviors in ASD include self-injury, aggression, verbal tantrums and other socially inappropriate behaviors (Beighley et al., 2013). Based on the reported occurrence difference, it is important to study how ASD symptoms may vary between boys and girls.

 

Problem Statement

ASD is one of the most common developmental disorders in the United States affecting more boys than girls in the ratio of 4:1 respectively. Even though females are affected less frequently than males, girls require a greater symptom threshold for clinicians to settle for an ASD diagnosis (Harrop et al., 2015). This implies that diagnosed cases of ASD in females are more likely to present with severe symptoms. In fact, other reports indicate that the sex ratio becomes evenly distributed in moderate to severe ASD.

Challenging behaviors form a notable part of ASD symptomatology even though they are not a basis for diagnosis (Hattier, Matson, Belva&Horovitz, 2011). In fact, children with ASD are more likely to present with challenging behaviors than any other psycho-developmental conditions (Kozlowski et al., 2012). The commonly cited challenging behaviors in ASD include destruction of property, aggression or injury directed to self or peers, tantrums, among others (Beighley et al., 2013; Hattier et al., 2011). These problematic behaviors can exacerbate the core deficits evident in ASD children leading to extrapolated implications on the child’s learning and social development.

While the prevalence of challenging behaviors among ASD children has been studied by various researchers, a few studies have aimed at advancing the glaring gender difference to these behaviors. Specifically, fewer studies have compared the occurrence of challenging behaviors between boys and girls and the results of pertinent literature are not conclusive. The purpose of this study is to determine the effect of gender on the presence and severity of challenging behaviors. This research is relevant because of the potential to provide useful insights on the management of ASD thus enhancing parenting and education.

Literature Review

Findings of previous researchers comparing the presence and severity of challenging behaviors between boys and girls are inconclusive. Kozlowski et al. (2012) compared challenging behaviors among 185 children with High-Functioning Autism (HFA), Asperger’s disorder, and typical development and their multivariate analysis of variance revealed no difference on challenging behaviors between boys and girls. However, the study reported racial differences in the manifestation of problematic behaviors. In a matched boy-girl comparison, Harrop et al. (2014) noted that boys and girls with ASD are more similar than different in terms of their social communication and children involvement in play activities. Nevertheless, some challenging behaviors in ASD (such as tantrums) are indirectly related to social communication.

On the other hand, Amr et al. (2011) explored sex differences among Arab children (aged 4-11 years) with ASD and identified increased instances of challenging behaviors among effected boys. However, Amr et al. (2011) used a relatively small sample of 37 boys and 23 girls. After analysis of data from the Autism360 online database, Baker and Milivojevich (2013) replicated the findings of Amr et al. (2011) that boys have more problematic behaviors compared to girls. The Autism360 is an online database in which ASD adults as well as caregivers of autistic children anonymously describe the ASD manifestations. Baker and Milivojevich used a sample of 1495 boys and 336 girls aged 2-18 years.

While the results of these studies may be valid, Kirkovski, Enticott and Fitzgerald (2013) noted that gender differences in the manifestation of ASD may be better observed in later stages of life, indicating that studies using toddlers may be limited. As evident in the studies, toddlers form a significant part of the study samples. Another cause for concern is the male dominance in prevalence. This disparity has led to the recruitment of fewer female subjects than males. Studies using significantly fewer female subjects compared to males indicates that comparisons made thereof may be limited. In a review by Kirkovski, Enticott and Fitzgerald (2013), the reviewers observed that Murphy, Healy & Leader (2009) reported no difference on challenging behaviors between boys and girls regardless of the obvious proportionate superiority in expression of challenging behaviors in girls. As Kirkovski, Enticott and Fitzgerald (2013) cited, Murphy et al. (2009) recruited 130 ASD boys and 27 girls. The proportion of girls with challenging behaviors was at 7.4% (2 cases out of 27) while for boys it was 2.3% (3 cases out of 130 boys).

Methods

Research Question and Hypothesis

Prevalence studies on (ASD) have indicated that the prevalence of ASD varies significantly between males and females, with the boys-to-girls ratio of about 4:1 (Baker &Milivojevich, 2013). Therefore, it is important to study how ASD symptoms may vary between boys and girls. This study aims at answering the following research question: Do girls with ASD manifest more severe challenging behaviors than boys with Autism Spectrum Disorder? The proposed study will test the following hypothesis: Girls with Autism Spectrum Disorder will have more severe challenging behaviors than boys.

Participants

The target population for this study are all elementary school children (age 5-10 years) diagnosed with ASD in Alabama. The Centers for Disease Control and Prevention (CDC) reported that the population of 8-year old children with ASD as of the year 2010 was 125 (Centers for Disease Control and Prevention [CDC], 2012). This number accounted for ASD children who were 8-years old at the time of data collection. The population of ASD children could be higher as the CDC surveillance program collected data in only nine counties; Blount, Cherokee, DeKalb, Jackson, Jefferson, Madison, Marshall, Shelby, and Tuscaloosa (Centers for Disease Control and Prevention [CDC], 2012). Nevertheless, the CDC report represents the average age of focus of this study (5-10 years).

For generalizability purposes, the sample should be derived from all the elementary schools in Alabama. However, this would not be possible because of resource constraints (time and money). Therefore, the participants will be selected from elementary schools in one county (Pike County).

This study will employ a probability sampling technique; specifically, stratified random sampling. This method is appropriate because of the well-recognized gender disparity in the prevalence of ASD. The male to female ASD ratio is about 4:1 (Baker & Milivojevich, 2013). Therefore, the accessible population will be divided into two strata based on gender, which is male and female.  Thereafter, participants will be randomly selected from the two strata; 80% of the sample from the male stratum and the other 20% from the male stratum. These sub-samples are representative of how the disorder affects the two groups. Because the participants are elementary school children, they will be recruited together with their parents or guardians. Accordingly, the sample will consist of parent-child dyads and only children whose parents give consent to participate in this study will be included.

Sample Size

The Yamane (1967) formula will be used to calculate the required size of the sample.

 

Where;      n = sample size

                  N= Total population

                  e = margin of error at CI of 95% (0.05)

Since N = 125 (Centers for Disease Control and Prevention [CDC], 2012).

          n = 125/[1+(125×0.052)]

          n= 95

Instruments

The independent variable in this study is gender while the independent variable is the manifestation of challenging behaviors. Challenging behavior is one of the common manifestations of ASD and include self-injury, aggression, verbal tantrums and other socially inappropriate behaviors (Beighley et al., 2013). The study will measure the presence and severity of the challenging behaviors using the Autism Spectrum Disorder-Behavior Problems for Children (ASD-BPC) scale (Matson, Gonzalez & Rivet, 2008). The ASD-BPC scale is one of a three-part tool used to assess for ASD symptomatology, comorbid conditions (psychiatric conditions), and challenging behaviors. The ASD-BPC has been widely utilized in the assessment of challenging behaviors and generally has high validity and reliability (Matson, Gonzalez & Rivet, 2008). The scale consists of 18 elements that assess for challenging behaviors. The parents or guardians will rate each of the 18 elements (challenging behaviors) depending on their presence and severity with 0 indicating that the challenging behavior is not a problem, 1 implying that it is a mild problem and 2 suggesting that it is a severe problem. After the scale is duly rated, the scores are summed up to get the overall score. The range of ASD – BPC is 0 – 36, with lower scores indicating the child behavior is less challenging.

Study Design

The study will employ a quantitative comparative design. According to Boswell and Cannon (2017), the comparative design is appropriate when the researcher has no intention of manipulating or controlling the independent variable with “the dependent variable being the only variable measured in two or more groups” (p. 115). This description perfectly fits with the procedures of the current study.

The study subjects will be divided into two groups of males and females. The presence and severity of the dependent variable (challenging behaviors) will be measured using the ASD-BPC scale. The total scores of all participants (the overall scores in the ASD-BPC scale) in each of the two groups will be added. Descriptive statistics will be used to summarize the data, including the mean score in each of the two groups. The investigator will then compare the means of the two groups to determine whether there is a difference in the presence and severity of challenging behaviors between the males and females. The researcher will then use inferential statistics to ascertain that the difference in the means (if any) is statistically significant, i.e. it did not arise by random chance. To achieve this degree of certainty, the analysis will employ a two-tailed t-test to determine the significance of the difference between the two means.

Audience Utilization of Possible Results

 The results of this study may be useful in advancing the meaning of the gender disparity in the prevalence of ASD. As Baker and Milivojevich (2013) noted, the meaning of the severe gender difference is limited. Importantly, the results will shed light on whether, professional counselors and therapists need to use different interventions in the management of ASD in girls and boys. Furthermore, the findings will provide useful insights to families with ASD children on the most effective coping strategies. This study will also guide teachers who are interacting with ASD children in the development of learning approaches best suited for girls with ASD. Lastly, the contributions of this research may be useful in devising effective coping mechanisms for the challenging behaviors that ASD children may manifest within the school settings.

References

  • Amr, M., Raddad, D., El-Mehesh, F., Mahmoud, E., & El-Gilany, A. (2011). Sex differences in Arab children with Autism spectrum disorders. Research in Autism Spectrum Disorders, 5(4), 1343-1350. doi: 10.1016/j.rasd.2011.01.015
  • Baio, J., Wiggins, L., Christensen, D., Maenner, M., Daniels, J., & Warren, Z. et al. (2018). Prevalence of Autism Spectrum Disorder Among Children Aged 8 Years — Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2014. MMWR.Surveillance Summaries, 67(6), 1-23. doi: 10.15585/mmwr.ss6706a1
  • Baker, S., &Milivojevich, A. (2013). Gender Differences among Children with Autism Spectrum Disorder: Differential Symptom Patterns. Global Advances in Health and Medicine, 2(6), 8-18. doi: 10.7453/gahmj.2013.003
  • Beighley, J., Matson, J., Rieske, R., Jang, J., Cervantes, P., &Goldin, R. (2013). Comparing challenging behavior in children diagnosed with autism spectrum disorders according to the DSM-IV-TRand the proposedDSM-5. Developmental Neurorehabilitation, 16(6), 375-381. doi: 10.3109/17518423.2012.760119
  • Boswell, C., & Cannon, S. (2017). Introduction to nursing research (4th ed.). Jones & Bartlett Learning.
  • Blumberg, S., Bramlett, M., Kogan, M., Schieve, L., Jones, J., & Lu, M. (2013). Changes in prevalence of parent-reported autism spectrum disorder in school-aged U.S. children: 2007 to 2011-2012. National Health Statistics Reports, Mar 20(65), 1-11.
  • Centers for Disease Control and Prevention [CDC]. (2012). ADDM fact sheet Alabama: A snapshot of Autism Spectrum Disorder in Alabama. Retrieved from https://www.cdc.gov/ncbddd/autism/states/addm-alabama-Fact-Sheet.pdf
  • Harrop, C., Shire, S., Gulsrud, A., Chang, Y., Ishijima, E., Lawton, K., &Kasari, C. (2014). Does Gender Influence Core Deficits in ASD? An Investigation into Social-Communication and Play of Girls and Boys with ASD. Journal of Autism and Developmental Disorders, 45(3), 766-777. doi: 10.1007/s10803-014-2234-3
  • Hattier, M., Matson, J., Belva, B., &Horovitz, M. (2011). The occurrence of challenging behaviours in children with autism spectrum disorders and atypical development. Developmental Neurorehabilitation, 14(4), 221-229. doi:10.3109/17518423.2011.573836
  • Kreiser, N., & White, S. (2013). ASD in Females: Are We Overstating the Gender Difference in Diagnosis? Clinical Child and Family Psychology Review, 17(1), 67-84. doi: 10.1007/s10567-013-0148-9
  • Matson, J., Gonzalez, M., & Rivet, T. (2008). Reliability of the Autism Spectrum Disorder-Behavior Problems for Children (ASD-BPC). Research in Autism Spectrum Disorders, 2(4), 696-706. doi: 10.1016/j.rasd.2008.02.003
  • Murphy, O., Healy, O., & Leader, G. (2009). Risk factors for challenging behaviors among 157 children with autism spectrum disorder in Ireland. Research in Autism Spectrum Disorders, 3(2), 474-482. doi: 10.1016/j.rasd.2008.09.008

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