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The use of BRIAAC for comparative study of autistic and low functioning deaf-blind children
Khan, Naeem Ul Haq, Ph.D. The Ohio State University, 1990
Copyright ©1990 by Khan, Naeem Ul Haq. All rights reserved.
UMI 300N.ZeebRd. Ann Arbor, MI 48106
THE USE OF BRIAAC FOR COMPARATIVE STUDY OF AUTISTIC AND LOW FUNCTIONING DEAF-BLIND CHILDREN
DISSERTATION
Presented in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy in the Graduate School of the Ohio State University
By
Naeem U. Khan, M.S.
**********************
The Ohio State University 1990
Dissertation Committee: Approved by
Charles Wenar tMl/^J
David Hammer Advisor
Thomas Linscheid Department of Psychology Copyright by Naeem U. Khan 1990 To My Fathers
ii ACKNOWLEDGEMENT S
I sincerely wish to thank my advisor, Dr. Charles Wenar, who made this study possible. Dr. Wenar's infinite patience, guidance and compassion leaves a life time of indebtedness. I also wish to thank my graduate committee members, Dr. David Hammer and Dr. Thomas Linschied for their support, interest, and encouragement throughout this study. I also wish to thank my Graduate School representative, Dr. Shirley 0'Bryant for reading the manuscript and for her valuable suggestions.
A grateful thank you is extended to Dr. Enid Wolf- Schien for providing very valuable support throughout this study.
I am specially grateful to the staff of Columbus Development Center for their encouragement, and for tolerating my frequent absences from work for academic pursuits.
Greatest appreciations go to my wife, Sameera who supported me throughout this project with her love, and to my children, Nasir, Uzma and Henna who tolerated my absences from home.
iii VITA
Name: Naeem ul Haq Khan Born: February 10, 1956, Quetta, Pakistan Education: 1972 General Certificate of Education, Tanzania 1976 Bachelor of Science, pre-medical University of The Punjab, Rabwah, Pakistan 1979 Master of Science, clinical psychology University Of Karachi, Karachi, Pakistan 1981 Ohio University, Athens, Ohio
Awards: Awarded Gold Medal for outstanding academic performance, University of Karachi, 1979
Awarded Ahmadiyya Centenary Gold Medal for academic excellence, 1979
Clinical experience: 1981-1982 State of Ohio, Certified Psychology Assistant, Apple Creek Developmental Center, Apple Creek Ohio. 1982-present Certified Psychology Assistant Columbus Developmental Center Columbus Ohio 1987-present Member, State Behavior Modification Committee, Ohio Department of Mental Retardation and Developmental Disabilities.
Field of Study: Psychology clinical child: developmental disabilities
iv TABLE OF CONTENTS
Acknowledgements iii Vita iv List of Tables .vi List of Figures .viii
CHAPTER I Introduction 1
CHAPTER II Literature Review Autism .6 Sensory impaired children 21 The congenital rubella child 41 Mental Retardation 53 Overlap of psychological variables 57 Hypothesis .73
CHAPTER III Methodology .76 Population Samples Studied. 76 Comparability of populations. 83 Instrument-BRIAAC 83 Experimental Design 88 CHAPTER IV Results SO
CHAPTER V Discussion 166
REFERENCES 193
v LIST OF TABLES
Table 1 F-Ratios of Behavior Checklist symptom areas in autism and other diagnostic groups 63 Table 2 F-Ratios of Behavior Checklist across demographic data for diagnostic groups 64 Table 3 Behaviors that differed significantly between autism and other diagnostic groups 66 Table 4 BRIAAC scores in various pathologies 72 Table 5 Age, sex, and etiological distribution of deaf- blind group 79 Table 6 Age and sex distribution of autistic group.... 81 Table 7 Age, sex and etiological distribution of mentally retarded group 84 Table 8 Basic statistics: autism 91 Table 9 Basic statistics: deaf-blind 92 Table 10 Basic statisticsrmentally retarded 92 Table 11 Basic statistics:deaf-blind rubella 93 Table 12 Basic statistics:deaf-blind non-rubella 93 Table 13 Autistic children: age effects 96 Table 14 Rubella deaf-blind children: age effects 98 Table 15 Non-rubella deaf-blind children: age effects.. 99 Table 16 Autistic children: sex effects 100 Table 17 Rubella deaf-blind children: sex effects 102
Table 18 Non-rubella deaf-blind children: sex effects.. 103 Table 19 Multivariate analysis of variance/Discriminant analysis:autistic ,deaf-blind and mentally retarded J. 07 Table 20 Group membership against predicted: autism,deaf-blind and mentally retarded 108 Table 21 Multivariate analysis of variance/Discriminant analysis: autism, rubella, non-rubella and mentally retarded 112
vi Table 22 Group membership against predicted: autism, rubella, non-rubella and mentally retarded.... 113 Table 23 Multivariate analysis of variance/Discriminant analysis: autism, rubella, rubella and non- rubella J. 16 Table 24 Group membership against predicted: autism, rubella, and non-rubella 117 Table 25 Multivariate analysis of variance/Discriminant analysis: autism and deaf-blind 122 Table 26 Group membership against predicted: autism, and deaf-blind 123 Table 27 Multivariate analysis of variance/Discriminant analysis: Autistic and rubella 124 Table 28 Group membership against predicted: Autistic and rubella 125 Table 29 Multivariate analysis of variance/Discriminant analysis: autistic and non-rubella deaf-blind. 127 Table 30 Group membership against predicted: Autistic and non-rubella deaf-blind 128 Table 31 Multivariate analysis of variance/Discriminant analysis:rubella and non-rubella deaf-blind...130 Table 32 Group membership against predicted:rubella and non-rubella deaf-blind 131 Table 33 Multivariate analysis of variance/Discriminant analysis:autism and mentally retarded 132 Table 34 Group membership against predicted: Autistic and mentally retarded 133 Table 35 Multivariate analysis of variance/Discriminant analysis:deaf-blind and mentally retarded 135 Table 36 Group membership against predicted: deaf-blind and mentally retarded 136 Table 37 Multivariate analysis of variance/Discriminant analysis: rubella and mentally retarded 138 Table 38 Multivariate analysis of variance/Discriminant analysis: non-rubella deaf-blind and mentally retarded 239 vii Table 39 F-ratios of all diagnostic groups when contrasted with autistic 140
Table 40 F-ratios of diagnostic groups when contrasted with mentally retarded 141 Table 41 F-ratios of diagnostic groups when contrasted with rubella deaf-blind 141 Table 42 Multiple comparison: relationship scale 145 Table 43 Multiple comparison: communication scale 145 Table 44 Multiple comparison: drive for mastery scale.. 14 6 Table 45 Multiple comparison:vocalization scale 146 Table 46 Multiple comparison:sound and speech reception scale 147 Table 47 Multiple comparison: social responsiveness scale 147 Table 48 Multiple comparison: body movement scale 148 Table 49 Multiple comparison: psychobiological scale...148 Table 50 Tukey's multiple comparison test: critical mean ranges for BRIAAC scales and mean scores of diagnostic groups. 14 9 Table 51 Pearson correlation matrix:autism 151 Table 52 Pearson correlation matrix: deaf-blind 152 Table 53 Pearson correlation matrix:mentally retarded.. 152 Table 54 Pearson correlation matrix:rubella 153 Table 55 Pearson correlation matrix:non-rubella 154 Table 56 Leik and Metthews test: autistic and deaf- blindchildren's data from present study in comparison to mean of mean errors of normal children's data from DCAC study and Kalish study 140 Table 57 Leik and Metthews test: Normal children's data from DCAC study and Kalish study 162
viii LIST OF FIGURES
FIGURE 1 Plot of mean scores on the BRIAAC scales for autistic, rubella deaf-blind, non-rubella deaf- blind and mentally retarded children 94
FIGURE 2 Scores of autistic, deaf-blind and mentally retarded children represented in a two dimensional discriminant space 109
FIGURE 3 Scores of autistic, rubella deaf-blind, non- rubella deaf-blind and mentally retarded children represented in a two dimensional discriminant space. 113
FIGURE 4 Scores of autistic, rubella deaf-blind and non- rubella deaf-blind children represented in a two dimensional discriminant space 118
ix CHAPTER I
INTRODUCTION
This comparative study of autistic and low functioning deaf-blind children empirically tests the clinical observation of autistic like behavior in the deaf-blind population by using the Behavior Rating Instrument for Autistic and other Atypical Children (BRIAAC). A control group of retarded non-autistic children has been included. Behavioral characteristics that can be objectively scored are the dimensions across which children who are autistic, deaf-blind and mentally retarded are compared.
Next, the study is concerned with the issue of whether autistic and low functioning deaf-blind children go through similar developmental progressions and how these compare with the development of normal children. Wenar (1982) proposes that a truly developmental psychopathology requires that: (1) all psychopathologies be viewed within a developmental context and (2) all psychopathologies be regarded as deviations from normal development. This conceptualization of psychopathology as "normal development gone awry" forces researchers and clinicians to adopt normal development as the basic context for viewing and 2 understanding psychopathological behavior. The research strategy in this format would thus involve the selection of certain psychological variables whose normal developmental course has been reasonably well charted, and then locating a group of deviant children and studying their progress in order to determine to what extent it follows a normal course and in what ways it deviates. The study of normal development and disturbed behaviors should enhance the understanding of both.
Present literature provides substantial data in regard to the normal course of development. Equally rich is the developmental literature on autism and mental retardation. The literature on autism is so extensive that by no means can an exhaustive survey be included here. The etiology of autism is not an issue or focus of this study. Instead the literature reviewed here will be concerned with the general developmental findings in regard to the specific psychological variables that are tapped by the instruments of this study and the literature pertaining to comparisons of the three groups in the identification and development of these specified psychological variables.
However the wealth of research on normal, autistic and mental retarded children cannot be matched with the 3 relatively small amount of empirical research that has been directed towards deaf-blind children. Unfortunately, there has been a shocking lack of attention given to these children by clinical and school psychologists and by child psychiatrists. What little information is available has typically been published in speciality journals for the sensory handicapped, and it is uncommon for the topic to be brought up in the course of training of clinical or school psychologists and psychiatrists (Matson and Hasel 1986) Research on the deaf/hearing impaired and on the visually impaired/blind children may bear little relevance to the deaf-blind child. Mclnnes and Treffry (1982) indicate..."the deaf-blind child has one of the least understood of all handicaps. He is not a blind child who cannot hear or a deaf child who cannot see. He is a multisensory deprived child who has been denied the effective use of both his distance senses". Much of the cited material has come from non-related bits and pieces of information where comparative and control populations were lacking. Text books on this population are few and generally present prescriptive teaching techniques based upon the author's/teachers' clinical and class room experiences. Outstanding treatment of specific topics has been slowly trickling in (Jones,. 1987, Mclnnes and Treffry, 1982) 4
Low functioning children have been called the diagnostician's challenge (DuBose, 1976). They have been regarded as untestable. Effective assessment is a real problem. Until recently, emphasis in assessment has been on school age children with a single disability. Assessment is not synonymous with testing. It is a much broader term, and measures a child's strengths and weaknesses educationally, psychologically, and medically, indications of developmental levels, and a profile of peer, family, and other interactions. It enables a team of specialists seeking remediation to make decisions about programming and necessary interventions that.can enhance the children's ability to function productively. Assessment is crucial because, before any educational placement can be made, a full and individual evaluation of each child must be conducted according to specified criteria.
Deaf-blind children are a population that is difficult to assess. Lack of adequate communication skills, interpersonal skills, and the inapplicability of accepted standardized tests as applied to normal children, require newer modes of assessment. Wolf-Schien (1988) has set forth the following "principles for the assessment of the deaf- blind children: 5 1. Nonintrusive measures are preferred to interactive ones. 2. The range of measurement must extend down close to zero. 3. Sensitivity to change must be exquisite. 4. The period of observation must be extensive. 5. Ipsitive scores are necessary. 6. Assessment must be linked to intervention.
"Among other suited measures is the BRIAAC (Behavior Rating Instrument for Autistic and other atypical Children, Ruttenberg, Kalish, Wenar and Wolf 1977) which was originally developed for use with children who have extreme problems with interpersonal relationships and communication as well as a variety of other atypical behaviors. It had been noted that many deaf-blind children shared some of these autistic behaviors and, in fact, that such deviant behaviors contributed significantly to the difficulties in working with them. Overall, this instrument has proved very effective with deaf-blind children. It fits the criteria for assessment instruments including the low floor and the fact that it is observational, requiring no direct involvement with the child being assessed. Because of its sensitivity, the BRIAAC reflects very minute changes in the behavior of an individual. It also takes into consideration behaviors important to consider but not usually found on an assessment scale" (Wolf-Schien 1988 p.2). CHAPTER II
LITERATURE REVIEW
ON AUTISM The study of autism has benefited from a developmental perspectives by comparing its psychological variables to their normal counterparts. Autism is a syndrome composed of a specified cluster of behaviors and a characteristic natural history (Rutter and Schopler 1987), with a broad range of symptoms and many defined sub-groups (Rutter 1978) . This syndrome was first described by Kanner in 1943 who was struck by the aloofness, isolation and lack of emotional contact displayed by some children.
Current educational issues for either re-certifying or decertifying populations for receiving specialized services have placed more demands for accurate diagnoses. Fundamental questions have been raised as to whether autism is a disease, a symptom (autisticlike symptoms), a mental illness, an emotional illness, a certain type of brain disease, a developmental disability, and/or a form of mental retardation.
6 7
According to the DSM III-R, autism constitutes a severe form of a pervasive developmental disorder with onset in infancy or early childhood. Pervasive developmental disorders of which autism is a part are characterized by a qualitative impairment in reciprocal social interactions, in the development of verbal and non verbal skills, and in imaginative activity. Often there is a markedly restricted repertoire of activities and interests which frequently are stereotyped and repetitive The severity and expression of these impairments vary greatly from child to child.
These disorders frequently are associated with a variety of other conditions. Distortions or delays in development are common in the following areas: intellectual skills, as measured by standardized intelligence tests ( in most cases there is an associated diagnosis of mental retardation); comprehension of meaning in language and the production of speech (in addition to problems in the social use of speech for reciprocal communication) ; posture and movements; patterns of eating, drinking, or sleeping; and responses to sensory input. 8 For a diagnosis of autistic disorder according to DSM
III-R at least eight of the following sixteen diagnostic items are present, including at least two items from A, one from B, and one from C. These criteria must be considered to be met only if the behavior is abnormal for the person's developmental level.
A. Qualitative impairment in reciprocal social interaction
as manifested by the following:
(1) marked lack of awareness of the existence, or feelings
of others
(2) no or abnormal seeking of comfort at times of distress
(3) no or impaired imitation
(4) no or abnormal social play
(5) gross impairment in the ability to make friendships
B. Qualitative impairment in verbal and non-verbal communication and in imaginative activity, as manifested by the following:
(1) no mode of communication, such as a communicative
babbling, facial expression, gesture, mime, or spoken
language
(2) markedly abnormal non-verbal communication, as in the
use of eye to eye gaze, facial expression , body 9 posture, or gestures to initiate or modulate social
interaction
(3) absence of imaginative activity such as playacting of
adult roles, fantasy characters, or animals; lack of
interest in stories about imaginary events
(4) marked abnormalities in the production of speech,
including volume, pitch, stress, rate, rhythm, and
intonation
(5) marked abnormalities in the form or content of speech
including stereotyped and repetitive use of speech
(6) marked impairment in the ability to initiate or sustain
a conversation with others, despite adequate speech
C. Markedly restricted repertoire of activities and
interests, as manifested by the following:
(1) stereotyped body movements
(2) persistent preoccupation with parts of objects or
attachment to unusual objects
(3) marked distress over changes in trivial aspects of
environment
(4) unreasonable insistence on following routines in
precise detail
(5) markedly restricted range of interests and a pre
occupation with one narrow interest
D. Onset during infancy or childhood. 10
The National Society for Autistic Children (Ritvo and Freeman, 1978) has taken the position that autism is a behaviorally defined syndrome. "The essential features are typically manifested prior to 30 months of age and include disturbances of: (1) developmental rates and/or consequences; (2) responses to sensory stimulii; (3) speech, language and cognitive capacities; and (4) capacities to relate to people, events and objects. (1) Disturbances of developmental rates and sequences. Normal coordination of the three pathways (motor, social- adaptive, cognitive) is disrupted. Delays, arrests, and/or regressions occur among or within one or more of the pathways: (a) within the motor pathways: for example, gross motor milestones may be normal, while fine motor milestones are delayed; (b) between pathways: for example motor milestones may be normal, while social-adaptive and cognitive are delayed; (c) arrests, delays, and regressions: for example motor development may be normal until age two when walking stops; some cognitive skills may develop at expected times, while others are delayed or absent; imitative behavior and/or speech may be delayed in onset until age 3, followed by rapid acquisition to expected developmental level. 11 (2) Disturbances to sensory stimulii. There may be generalized hyperactivity or hypoactivity, and alteration of these two states over periods ranging from hours to months. For example, (a) visual symptoms: these may be close scrutiny of visual details, apparent non-use of eye- contact, staring, prolonged regarding of hands or objects, attention to changing levels of illumination; (b) auditory symptoms: these may be close attention to self induced sounds, nonresponse, or over response to varying levels of sound, (c) tactile symptoms: these may be over or under response to touch, pain and temperatures, prolonged rubbing of surfaces, and sensitivity to food textures; (d) vestibular symptoms: these may be over or under reaction to gravity stimulii, whirling without dizziness, and preoccupation with spinning objects; (e) olfactory and gustatory symptoms: these may be repetitive sniffing, specific food preferences, and licking of inedible objects;
(f) proprioceptive symptoms: these may be posturing, darting-lunging movements, hand flapping, gesticulations, and grimaces.
(3) Disturbances of speech, language-cognition, and non-verbal communications. Symptoms may include: (a) speech: for example, mutism, delayed onset, immature syntax, and articulation, modulated but immature 12 inflections: (b) Language-cognition: for example, absent or limited symbolic capacity, specific cognitive capacities, such as rote memory, and visual-spatial relations intact with failure to develop the use of abstract terms, concepts; neologisms; (c) nonverbal communication: for example, absence or delayed development of appropriate gestures from language, and failure to assign symbolic meaning to gestures.
(4) Disturbances of the capacity to relate appropriately to people, events, and objects, manifested by failure to develop appropriate responsivity to people, and assignment of appropriate symbolic meaning to objects. For example, (a) people: absence, arrests, and/or delays of smiling response, stranger anxiety, anticipatory response to gestures, playing "peek-a-boo", playing "patty-cake", and waving "bye-bye", reciprocal use of eye contact and facial responsivity, and appropriate reciprocal responsivity to physical contact; failure to develop a relationship with significant caretakers. For example, caretakers may be treated indifferently, interchangeably, with only mechanical clinging, or with panic on separation. Cooperative play and friendships (usually appearing between 2 and 4) may not develop. Expected responses to adults and peers (usually appearing between 5 and 7) may develop but 13 are superficial, immature, and only in response to strong social cues; (b) Objects: absent, arrested, and/or delayed capacities to utilize objects and/or toys in an age appropriate manner and/or to assign them symbolic or thematic meaning. Objects are often used in idiosyncratic, stereotypic and/or perseverative ways. Interference with this use of objects often results in expression of discomfort and/or panic; (c) events: There may be a particular awareness of the sequence of events and the disruption of this sequence may result in expression of discomfort and/or panic."(Ritvo and Freeman, 1978).
Since Kanner's observations no single etiology or pathology has accounted for all cases of autism and many research projects indicate that autism is a "final common expression" of a number of multiple determinants. Such etiological diversity may obscure underlying mechanisms (Cohen and Shaywitz 1982). Additionally, researchers differ on exactly which behavioral characteristics are necessary for the diagnosis of autism. Very few children diagnosed as autistis exhibit every symptom exactly as described by Kanner, and not all autistic children are of the same level of severity. The heterogeneity has led to confusion both in diagnosing autistic children, and in choosing suitable comparison groups for research purposes. 14
It is all too apparent that there is no readily recognizable separation point between "true" autism and other disorders that share some behavioral features but which do not fulfill the complete set of accepted diagnostic criteria. Of course, ' in reality, such a differentiation could only be based on some unequivocal indication of some specifically and uniquely autistic feature. Such a feature has yet to be identified (Rutter and Schopler 1987). Despite extensive research efforts over the part two decades, unfortunately no documentation has been found for psychogenic models, no biological markers identified and no specific pathological process pinpointed (Ornitz and Ritvo,1976). However, patients with strikingly similar behavioral and developmental disabilities have been carefully documented to exist throughout the world. Their natural history is remarkably similar despite their cultural, social, and geography heterogeneity.
The symptoms often occur in association with others which are known to be indicative of different syndromes (epilepsy, mental retardation) and /or other specific diseases (e.g. rubella, Down's syndrome) (Ritvo and Freeman). Coleman (1976), has grouped the population into three main categories: the classical autistic, childhood 15 schizophrenics with autistic features, and neurologically impaired autistic children. Thus, it should not be surprising that one reason for this heterogeneity is thatl, in many cases, autism appears to overlap with several other childhood disorders. Sometimes this is because autism is a by product of a specific known pathology, such as congenital rubella or phenylketonuria. It may result from metabolic, infectious, developmental, genetic, and environmental insults (Ciaranello, Vandenburg, and Anders 1982) .
Rutter (1987), outlines five areas of controversy with respect to the boundaries of autism as a valid diagnostic entity. (1) autistic like syndromes in children with severe mental handicaps, (2) autistic like disorders in individuals of normal intelligence with gross developmental delay, general or specific, (3) later onset autisticlike disorders following a prolonged period of normal development, (4) severe disorders arising in early or middle childhood characterized by grossly bizarre behavior, and (5) the overlap between autism and severe developmental disorders of receptive language. While autism may represent a clinical syndrome, autistic children share characteristics in common with mentally retarded children and with children having other handicapping conditions. 16
Ritvo and Freeman (1978) note that the associated clinical features with autism vary with age and include other disturbances of thought, mood, and behavior. Mood may be labile; crying may be unexplained or unconsolable; there may be giggling or laughing without identifiable stimuli. Delusions and hallucinatory experiences have been reported. There may be a lack of appreciation of real dangers such as moving vehicles and heights as well as inappropriate fears. Self-injurious behaviors such as hair pulling and hitting and biting parts of the body, may be present, and stereotypic and repetitive movements of limbs or the entire body are common. Current research estimates are that approximately 60% of autistic children have measured IQs below 50; 20% percent between 50 and 70, and 20% of 70 or more. The majority show extreme variability of intellectual functioning on formal IQ testing. They perform poorest on tasks requiring abstract thought, symbolism, or sequential logic, and best on those assessing manipulative or visual- spatial skills and rote memory. Some studies indicate the there is a common occurrence of grand-mal and psychomotor seizure activity in many autistic children. In fact the incidence of EEG abnormalities increases with age, as does the possible onset of seizures. 17 Conversely, autisticlike behavior has been found in children with sensory and neurological disorders. Such autistic behavioral pattern include subclusters of symptoms that may be interpreted as disturbances of sensory modulation and motility (Garreau, Barthelemy, Sauvage, and LeLord 1984). In a comparative study autistic children have been shown to have a greater degree of conductive hearing loss than that found in learning disabled or normal groups (Smith, Miller, Stewart, Walter, and McConnel, 1988). The nature of basic deficit in autism is being investigated in terms of measurable variables. Language development is being seen in terms of motor imitation problems, poor auditory processing and other hidden soft signs which Kanner was not aware of.
In terms of etiology, Rutter and Shopler (1987), (p. 161-162) emphasize "that autism differs in so many ways from the ordinary run of emotional and behavioral disorders of childhood that its distinctiveness is beyond dispute. It stands out in its strong association with mental retardation and with organic brain dysfunction, as well as in its worse prognosis, and its persisting differences in symptomatology. Over three quarters of autistic children are mentally retarded. Nevertheless autistic children have been found to differ sharply from non-autistic mentally 18 handicapped children of comparable mental age. Thus although seizures occur in about a quarter of autistic children, they differ from non-autistic mentally retarded with respect to age of onset, in sex distribution, in patterns of cognitive disability and in their discrimination of socio-emotional cues."
"On the face of it, autism might seem to be very similar to the most severe developmental disorders of receptive language. Indeed there are some similarities and some overlap. However there are also marked differences in terms of its sex distribution and its worse prognosis, its patterns of cognitive disabilities (both wider and more severe in autism, even after equating for language handicap) and its persisting pattern of socioemotional behavioral abnormalities." (p.162)
Interpersonal hypotheses typically regard perceptual, cognitive, and linguistic dysfunctions as consequences of faulty care taking. The underlying assumption is that care taking mediates every facet of development. If care taking is highly deviant, all other development will be distorted. The views on the nature of family factors in the genesis of autism are many. However they may be grouped under three general headings: (1) severe stress during the child's 19 early life; (2) deviant parental characteristics and ; (3) deviant parent-child interactions. An awesome glossary of pejorative epithets have been applied to the parents of autistic children. Some of these labels are as follows: cold, refrigerator mothers, undemonstrative, introvertive, obsessive, overprotective, symbiotic, indecisive, lacking, dominance, showing perplexity resulting in lack of spontaneity, psychic paralysis and the insidious double bind. Empirical data do not confirm these views of parental pathologies. There is unequivocal evidence that pathological family factors are not a sufficient cause for the development of autism (Rimland, 1964; Cantwell, Baker, and Rutter, 1978) . It is true that abnormalities in rearing can lead to serious social problems, but the nature of the social abnormalities differs markedly from that found in autism. Institution reared children tend to be clinging and excessively friendly in an indiscriminate fashion and abused children show marked insecurities in their personal attachments. Neither feature is characteristic of autism. Thus, conclude Rutter and Shopler (1987), there is no doubt that autism constitutes a valid and a meaningful different psychiatric syndrome; indeed, the evidence on its validity is stronger than for any other psychiatric condition in childhood. 20 Conditions that give rise to widespread organic brain dysfunctions may sometimes cause patterns of brain pathology that affect the systems that underlie autistic abnormalities. It is also found in a variety of medical conditions. It is relatively common with infantile spasms or congenital rubella. It appears that there must be something particular about the pathological process that give rise to autism, although what that is remains obscure. Most autistic children do not show any gross structural abnormalities of the brain— at least not as evident on the basis of the data from the techniques used so far. Although autistic children show a modest increase in perinatal complications, the increase is not mainly in the more severe complications associated with brain damage. However, the Fragile-X phenomena has accounted for 5-17% of autistic cases indicating a genetic factor. There is undoubted etiological heterogeneity within the autistic syndrome that account for a minority of cases of autism. Clinical picture of autism can arise from congenital rubella, tuberous sclerosis, encephalopathy, infantile spasms and neurofibromatosis. In vast majority of cases there is no identifiable medical cause. Accordingly, it remains quite uncertain whether the minority of cases with a known pathological cause represent phenocopies of some other unitary disorder with a (an as yet undiscovered) single 21 etiology, or whether the behavioral syndrome represents just the final common pathway for a diverse range of organic brain conditions that happen to impinge on similar brain systems. In order to decide between these contrasting alternatives, it is essential to have a systematic research that focuses on the question of the heterogeneity within autistic syndromes. It will be appreciated that such research must go well beyond the mere noting of heterogeneity. It is crucial that it is designed to determine the ways (if any) in which the diversity on one parameter coincides with diversity on other dimensions.
ON SENSORY-IMPAIRED CHILDREN WITH PARTICULAR REFERENCE TO DEAF-BLIND CHILDREN
Under normal conditions, the young child learns the visual skills of fixation, tracking, focus, accommodation, and convergence through looking during day-to-day activities. The visual system is extremely important for learning because a greater quantity of information can be gained in a shorter period of time than through any other single sensory system. When the human eye is operating at the maximum capacity, the 900,000 fibers of the optic nerve can transmit 430 times as much information to the brain per 22 second as 30,000 fibers of the human ear. Vision is the mediator for other sensory impressions and acts as a stabilizer between the person and the external world.
The impact of severe visual impairment permeates every phase of growth and development and retards developmental progress. A severe deficit in vision causes a delay in the acquisition of many skills, including the gross and fine motor skills of reach and grasp, eye-hand coordination, muscular control of the head, neck, and trunk muscles, eye- foot coordination; walking and play (Scholl, (1986). The lack of visual stimulation may result in a lack of motivation to move and explore the environment.
A deaf-blind or a blind child's visual system may not function properly for a number of reasons including the following: (1) the retina of the eye does not receive light (e.g., retinal detachment, retinitis pigmentosa); (2) the retina of the eye does not receive a clearly focused image (e.g., fibrolental hyperplasia); (3) optic nerve impulses do not reach the vision center of the brain (e.g., optic atrophy); or (4) information from the eye is not processed by the brain (Blackman, (1984) . 23 The deaf-blind criteria is primarily a legal-medical classification system requiring an estimated visual acuity.The following are generally accepted criteria for vision: 1. Measured or estimated corrected visual acuity of 20/100 or less in the better eye, and/or a previous chronic visual condition has existed which has interfered with the visual learning mode. 2. In the presence of normal peripheral vision apparatus as determined by an ophthalmologist, cortical blindness is determined; this blindness must be verified by reports indicating an absent optokinetic nystagmus as appropriate to age by an ophthalmologist, a pediatrician, or a pediatric neurologist. 3. Field vision of 20 degrees or less in the better eye. 4. Visual acuity cannot be accurately measured, and the student is suspected to be blind, thus "functionally blind". "Functionally blind" means that that the student does not visually track, localize, or use his or her vision appropriate to the overall developmental level(s) as determined by appropriate assessment of development.
Auditory deficits, particularly during the developmental years, severely impact normal development in the acquisition of receptive and expressive language, in 24 concept development particularly involving abstract problem tasks, in social development, and interpersonal relationships, and in school-related activities involving reading and language based skills. Some of the disadvantages the hearing impaired child experiences in language development stem from (1) inadequate auditory feedback from babbling and language attempts, (2) inadequate verbal reinforcement from adults, (3) inability to hear an adult language model, and (4) inadequate mother- child language stimulation interaction.
The ability to hear normally is a complex function which requires not only a healthy receptor, the ear, but also an intact nervous system. The major types of hearing impairments include peripheral hearing losses (conductive, sensorineural, mixed), brainstem hearing loss, cortical hearing loss and a functional hearing loss.
The deaf criteria is primarily a legal-medical classification system requiring hearing sensitivity. The following are generally accepted criteria for hearing: 1. Thirty db bilateral sensory neural hearing loss as a minimum across the speech frequency in the better ear with amplification and/or a previous chronic condition of the 25 auditory mechanism has existed which interfered with the auditory learning mode. 2 Sensitivity and middle ear functioning cannot be definitively measured and the student is suspected of being deaf, thus "functionally deaf". "Functionally deaf" means that the student does not auditorily attend to, respond to, or localize sounds, or use his hearing appropriate to his or her developmental level as determined by appropriate assessment of development.
Deaf-blind low functioning children are frequently very difficult to evaluate auditorily due to low cognitive and motor functioning as well as low auditory and vision functioning levels. Without language, it is difficult to accurately assess the hearing acuity using traditional audiometry techniques.
The causes of deafness and of blindness are too numerous to list here. However, when considering congenital deaf-blindness the causes can readily be narrowed to a few. The incidences of congenital deaf-blindness are not stable. Major peaks occurred during the rubella epidemic in the 1960s in the U.S.A. 26 Descriptive studies of particular problems have been reported. For example, Green and Schecter (1966) describe three blind children referred to a child psychiatric clinic. The children were described as severely disturbed and withdrawn and lacking in many types of environmental support. Developmental retardation such as poor speech and the failure to reach many age-appropriate gross and fine motor skills were reported.
From a developmental viewpoint, visual handicaps can result in a slowing of emotional and psychomotor development. For example, children learn to crawl slowly since visual cues are lacking. Also crawling, grasping, and so forth are often enhanced by a child's wish to obtain interesting objects such as toys. The withdrawal and passivity noted, when present, may result in marked impairment in terms of development since the child does not obtain sufficient practice to improve cognitively or motorically at a normal rate. Such developmental retardation may lead to other forms of emotional disturbance in the visually handicapped children.
Particular types of visual handicaps may also be important factors in the severity and type of emotional problems displayed. Barry and Marshall (1953) discuss this 27 problem with respect to retrolental fibroplasia, one of the frequent causes of blindness in children. Typical symptoms are engorgement of retinal vessels followed by hemorrhage, retinal detachment and other irreversible changes in the first few weeks of birth. Some of these children appear to be mentally retarded, and many others show signs of emotional disturbance. Barry and Marshall (1953) studied 17 kindergarten children with retrolental fibroplasia using 13 blind children with other etiologies as controls. They were measured on the basis of teacher ratings on a series of affect and adaptive responses. It was found that maternal rejection was apparent in many instances and that a strong relationship between parental acceptance and success and parental rejection and failure existed.
Haspiel (1965), evaluated 60 visually impaired, emotionally disturbed children with communication problems. This researcher concluded that the lack of visual stimulation can result in a very slow development and may be associated with the development of a number of stereotypic behaviors.
Another problem of low vision students is that they often function as chronic underachievers in school. Those children with average intelligence lagged one year behind 28 their normally sighted counterparts in overall academic achievement and almost two years behind in grade placement. These problems seem to be evident whether the child had low vision or was blind.
Another problem is psychomotor retardation. Maxfield and Buchholz (1975) found major developmental deficits among blind infants, particularly in situations requiring self-initiated mobility. Daugherty and Moran (1982) studied 50 children using the Halstead Reitan Neuropsychological Battery, The Stephens Piagetian Battery of Reasoning and standardized achievement tests. They found significant delays in cognitive and psychomotor development and academic achievement. Thus, the relationships among a number of emotional factors and achievement appears to be well-established in this visually impaired group.
The main presenting features of some blind children are identical to those presenting in autistic children including self-isolation, lack of appropriate use of language, stereotypes, inappropriate use of objects, a pre occupation with music, and abnormal motility patterns (toe walking, body rocking, bizarre choreoathetotic posturings) (Konstantareas, Hunter, and Solmam, 1982). That autism can co-exist with blindness is found in the study of Coleman 29 (1976) where co-existence of sensory deprivation such as blindness is considered with autism to fall in the rubric of "neurologically impaired" autistic sub-group. Very early on, Keeler (1958) observed the similarity in history and clinical picture of some blind children to that of autistic children and proposed that a combination of emotional neglect due to prolonged absence of mothering," or maternal rejection, near total blindness from birth, and perhaps brain damage might have contributed to these children's pathology. Blank (1975) reported a 25% incidence of severe autistic symptoms in congenitally blind children.
Fraiberg's (1977) multi-faceted study of blind children is a classical example of autistic behavior in a population with a sensory disorder. Fraiberg worked with 27 blind children from ages three months to fourteen years, and noted that at least 7 presented a clinical picture that closely resembled autism in the sighted. She writes "there were stereotyped hand behaviors, rocking, swaying, mutism or echolalic speech. These were children who were content to sit for hours, sucking on a clothes pin or a pot lid, rocking, detached, vacant, virtually unresponsive to the mother or any other human being. The most striking feature of these cases was their uniformity. We had the uncanny feeling that we were seeing the same case over and over 30 again. Of the remaining 20 children, nearly all showed one or another form of stereotyped motility and idiosyncratic mannerisms. But they differed from the first group in having attained some level of ego functioning, a differentiation of "self" and "other," of "I" and "you": language which served at least elementary communication. In contrast with the first group, these children had human ties, but the bonds were precarious, and it was not unusual to see children in the late school years who were reduced to helplessness during the absence of a parent or a teacher. Several of these children at school age were clearly unable to master Braille. Their hands, which, it is said, are "the eyes of the blind," could not discriminate among objects or forms and seemed to bring them little information about the world outside their bodies. For most of the children there was no evidence of neurological impairment, but this did not rule out the possibility of damage due to unknown causes" (p 3-4).
"The question of possible brain damage is still debated in the literature of both the sighted and the blind autistic child. It is entirely possible that the clinical picture of autism can be produced by either central impairment or gross impoverishment in the stimulus nutriments for early sensorimotor organization. A child who 31 cannot register experience because of central impairment and a child who cannot register experience because his world is empty may produce the same clinical picture we call autism. This picture of arrested development in the blind is one that was found repeatedly in the literature that was examined. Further evidence pointed to the fact that the clinical picture of deviant ego development was not associated with any specific etiology for blindness, and that the gross abnormalities encountered in certain blind children appear to be associated with total or nearly total blindness from birth and a history of inadequate emotional stimulation in the early months of life" (p. 4- 5). Fraiberg further reasoned that for every developmental failure in the blind autistic child there should be a correlate in the development of blind babies in the form of a unique adaptive problem posed by blindness. The difference between the autistic blind child and the child in the "normal" group should appear in developmental studies in which one group found the adaptive solutions and the other group met a developmental impasse.
The difficulties of the hearing impaired children are perceived by many to be even more severe than those of the visually impaired and the magnitude is increased by the numbers involved (Matson and Helsel 1986). The discussion 32 of emotional problems with the hearing impaired has received considerably more attention than has been the case with the visually impaired in terms of the number of research articles published. What is apparent from these articles and those with the visually handicapped is that both groups share a greater prevalence of psychopathology than is the case with the population at large.
The study of emotionally disturbed hearing impaired children began as early as 1938. Springer (1938) found greater levels of psychoneurotic tendencies in the hearing impaired than in the general population and these results were confirmed by Myklebus and Burchard (1945) several years later. Meadows and Schlesinger (1975) identified emotionally disturbed children at a school for the deaf. Of the 516 students, 11.6% were identified by teachers as severely emotionally disturbed and 101 or 19.6% were identified as having problems of a lesser but a significant degree. Gentile and McCarthy (1973) surveyed 42,513 students in special education in a national study and found that 32% of the students had one or more additional handicaps with the most frequent of these being emotional problems. Among the school age group of children and adolescents, 18.9% had emotional problems which were 33 considered to have significant negative effect on their ability to succeed in school.
Psychiatric problems, especially personality disorders, neurosis, and behavioral disorders in children and adults are reported to be particularly prevalent in the hearing impaired (Altshuler, 1974, Malkin and Hasting, 1975) . It has also been argued that aggression and impulsive behavior are high, with relatively low rates of severe depression and obsessive compulsive behaviors. Additionally the prevalence of schizopherenia in the prelingually deaf is similar to that found in the normal population, whereas the hard of hearing are overrepresented among samples of persons suffering from paranoid schizophrenia in later life (Cooper, 1976)
Some developmental problems are also frequently present and may contribute to the emotional problems of the hearing impaired child. Altshuler (1974) points out that sound can evoke emotion and thus the two are interrelated. For example, tone of voice may convey anger, support, or joy. These considerations are important in determining the degree and quality of social interactions. Also since the hearing handicap is not always apparent, people may often 34 react adversely though not realizing that the problem exists.
Degree of hearing impairment is another factor to consider. Bowyer and Gilles (1970), who evaluated partially deaf children, noted more socio-emotional problems among this group than among severely deaf children.
Another crucial problem is the relationship of hearing impairments to other potential problems. The overlaps in various handicaps has been noted for along time. Schein (1974,75) enumerates incidences of mental retardation with deafness and other disabilities including physical and visual.
A deaf-blind resource manual (Georgia State Dept. of Education, 1980) reports that that sensory deficits frequently observed among deaf-blind children include nystagmus, strabismus, congenital cataracts, sensory-neural hearing loss, and high frequency hearing loss. The manual indicates physical defects of deaf'-blind children frequently include a small frail body, microcephaly, heart defects, and a lack of coordination. Additionally the deaf- blind children often display developmental delays of cognition. The manual reports that the rubella syndrome 35 deaf-blind persons frequently exhibit the following behaviors: eye-poking, rocking, hand flicking, gazing at light, teeth grinding, perseveration of vocalizations or movements, delayed acquisition of self-help skills, delayed motor skills, delayed communication skills, erratic behavior, and no obvious response to environmental sounds.
Professional personnel with the deaf-blind Program of Special School District of St. Louis County, Missouri (1985), found that general characteristics of young (4-9 years old) deaf-blind children in their program included the following: 1. Intelligence: functioning within the severe/profound mental retardation range with a mental age of 0-4 months. 2. Communication: No speech. Verbal communication consists of vocalizations to indicate discomfort or pleasure. 3. Self-Help Skills: Totally dependent— unable to self- feed, unable to self dress, not toilet trained. 4. Visual skills: Severe visual impairment. 5. Auditory Skills: Moderate to severe hearing loss. 6. Fine and gross motor skills: Severe psychomotor retardation, some form of cerebral palsy, and non ambulatory. 36 7. Medical concerns: Seizure disorders, frequent upper respiratory health concerns. 8. Interpersonal Relationships: Lack of peer relations, no spontaneous interactions. Generally appeared to recognize primary care givers. 9. Interactions with environment: No interactions with their environment; little cause and effect understanding. 10.Other Behavioral Concerns: Self-stimulatory behaviors, rumination, severe behavior disorders, tactile defensiveness, temper-tantrums, eye gouging.
Mclnnes and Treffry (1982) indicate that the deaf- blind child has one of the least understood of all handicaps. He is not a blind child who cannot hear or a deaf child who cannot see. He is a multisensory deprived child who has been denied the effective use of both his distance senses.
The senses of sight and hearing are unquestionably the two primary avenues by which information and knowledge are absorbed by an individual, providing a direct access to the world in which he lives. These two senses account for the great majority of experiences by which one learns through observation and conscious imitation the activities and the 37 mores that are most acceptable to the society and that develop intelligence, maturity and social habits. When these senses are lost or severely limited, the individual is drastically limited to a very small area of concepts, most of which must come to him through his secondary senses or through indirect information supplied by others. The world literally shrinks; it is only as large as he can reach with his fingertips. The severe limitations of sight and hearing, or their complete absence, may result in isolation and loneliness. Loneliness may be imposed on an individual by other people; he may be shut-out, neglected, even when companionship is what he most desires. Many deaf- blind persons are extremely self-centered and even selfish because they are most conscious of their own immediate wants and needs. They tend to develop psychological barriers and behavior patterns to protect themselves and most often these' patterns are not acceptable in the society. Temper-tantrums, irresponsiveness to others, and careless habits of personal hygiene and social behavior are just a few of the mechanisms that may be used for self- defense and self-protection (Walsh & Holzberg 1981).
A number of limited efforts have been made through the years to enhance interest in the emotional problems of visually impaired persons and the need to address them, but 38 the lack of interest in research has shown that these efforts had little impact. A number of correlational studies have appeared, and in most instances efforts have been made to compare and contrast children with visual handicaps to those with sensory handicaps or mental retardation. However, efforts of this sort must be gauged from the stand point that factors other than sensory impairment alone may contribute to the children's problem. Thus, for example, segregated classrooms, differences in expectations placed on the children, and a number of related factors may cause at least part of the overall behavioral patterns. Yet, as will be evident from the state of art in research in this topic, there are marked differences between normal children and visually impaired emotionally disturbed groups.
Brown (1939), in one of the earliest of these comparative studies, found that marked differences were evident from the Clark Revision of Thurstone Personality Schedule, between 218 children from a school for visually handicapped and 359 high school seniors in a regular school program. Brown found that "greater neurotic tendencies" were evident in the visually handicapped group with no marked sex differences. In a related study Morgan (1944) used a test called the Personality Index. However, only a 39 group of children from a school of visually handicapped participated, with 62 boys and 66 girls in the sample. They averaged 15.8 years, with 2.9 years below grade level, although their IQs were near the mean for the general population. Greater lag in grade level was attributed largely to their visual handicap. Greater maladjustment was noted in this group compared to regular public school children. Speech impediments, lower intellectual functioning and related factors may further compound the emotional problems of these children. Very bright children from this sample were better adjusted.
Heinze, Matson, Helsel, and Kapperman (1985) found emotional problems to be more frequent in visually impaired children than in the overall population. They evaluated 75 visually handicapped children on the Child Behavior Checklist, Revised Behavior Problem Checklist, School Behavior Checklist, and the Problem Checklist. This study was one of the few that used instruments with well- established psychometric properties. It was found that a strong relationship among forms of psychopathology existed across scales, suggesting that it may be possible to evaluate the problem more accurately. It was also apparent that the range of symptoms across types of psychopathology varied to some degree from symptoms observed in the 40 population at large, with somatic complaints and hyperactivity being particularly prevalent.
The issue of sensory deprivation becomes even more acute when both visual and auditory apparatuses have been involved. According to Sontag, Burke and York (1973), many deaf-blind students have characteristics similar to severely/profoundly mentally handicapped children including self-stimulation and/or self mutilation, a lack of self- help skills, a lack of communication skills, a lack of socialization skills and numerous medical concerns.
Thus we find that references in literature to a high incidence of autism like pathology in congenitally blind children, but little if any has been explicitly documented in congenitally both deaf or severely hearing impaired and blind or severely visually impaired children who are also low functioning. Behavioral observations abound but the fact remains that as yet we have very little systematic evidence documenting the possible obvious or more subtle differences in the symptomatology of deaf-blind children who develop autism and their non-deaf-blind counterparts. 41 THE CONGENITAL RUBELLA CHILD
Autism has been reported to be a possible by product of brain infection in children whose mothers had suffered from maternal rubella during pregnancy. Most often the severe effects of congenital rubella in children include loss of vision and hearing and other complications. Many other behavioral problems have also been linked to these children. Most of the deaf-blind children in the present study had congenital rubella and as such the clinical picture of the rubella child is surveyed in this section.
Kirman (1955) reported on mentally defective children whose deficiency was thought to be due to maternal rubella. He reviewed records of seven children during the six years they had been hospitalized and found that "apart from the intellectual limitations there are no special psychological features common to this group".
Bindon (1957) administered intelligence, Rorschach, and fantasy production tests to rubella deaf, non-rubella deaf, and normal children, and found that the rubella deaf perform no differently from non-rubella deaf-children. However, as a result of their retarded language 42 development, both deaf groups functioned at a less matured level than hearing youngsters, even though the researcher could find no specific personality patterns to differentiate the subsamples.
Sheridan (1964) found little support for the theory that the rubella children often show emotional instability and difficult behavior. He studied a group of 227 young subjects aged eight to eleven years. Fifteen percent of them had major abnormalities and a further 16% had minor defects. A total of 2 9% had some significant degree of hearing loss, and in 17 of these children deafness was first diagnosed at this time. Although specific behavioral information was requested for each child, the records noted only that 12 were shy, immature, lacking in concentration or labile to outbursts of temper. Only one child was reported to be psychologically difficult. The IQ test scores of 191 children in this group showed a normal distribution, with a range of 63 to 160. This enquiry produced no evidence that mental subnormality is a common sequel of early maternal rubella.
Lavine (1951) investigated 16 children whose mothers had had rubella during pregnancy and all but three of whom had one or more physical defects. Thirteen of these three 43 to four year olds were quite like other small deaf children in their general behavior and responsiveness to play and to people except that they showed a greater tendency to hyperactivity, tenseness and low stimulus threshold. No evidence of emotional disturbance could be found to account for this. The other three children were highly atypical in all their observed reactions. Their behavioral pictures seemed to combine infantile characteristics, defective mentality, inappropriate emotional responsiveness, and queer motor mannerisms. Their general behavior was strongly suggestive of some type of brain damage or disease.
In a study of 57 youngsters aged three to five years, Jackson and Fisch (1958) found that the children with the most severe degree of bilateral deafness showed an abnormal behavior pattern including restlessness, destructiveness, spitefulness, and inability to concentrate.
Lundstrom (1951) began a longitudinal study of children born with the disease in the 1951 Swedish epidemic of rubella. One of their aims was a systematic controlled investigation of the mental development of children of school age with a history of maternal rubella. They compared a group of rubella children with controls using information on the youngster's performances on school 44 maturity tests and teacher's answers to questionnaires to determine the psycho-educational progress of both groups. Of the 44 9 rubella and 403 normal children who had taken the Swedish school maturity tests, a significantly higher percentage of youngsters whose mothers had rubella during the second month of pregnancy (26%) were found to be unready for school than the controls.
Desmond et al (1967, 1967) followed rubella syndrome infants for 18 months. Eighty one of their original 100 patients showed neurological abnormalities of varying degree between birth and one year. At 18 months of age 44 of 63 survivors continued to show neurological residua including a wide range of motor deficits, hyperactivity, restlessness, convulsions, stereotyped movements and poor progress in adaptive behavior. The median levels of motor development, language development, adaptive behavior, and personal-social behavior for the group were all below average at 18 months. Infants with multiple handicaps had the lowest scores. Eight infants appeared autistic, isolated, and out of communication with the environment, and eleven had made virtually no progress in adaptive behavior over the prior 6 month period. 45 Freedman, Kolenda and Brown (1970) offer the description of the development of one rubella baby during his first 18 months of life. They conclude that the child fulfills most of the criteria Rimland lists as necessary but not sufficient for the diagnosis of infantile autism. Organismic and environmental factors operated to produce atypical and maladaptive patterns to concrete experience.
Vernon (1969) studied rates of emotional disturbance in the hearing impaired rubella children. He employed teacher's ratings and psychological evaluations for 1,400 students classified as severely disturbed and children dismissed from school because of emotional disturbance. He found that the average intelligence of the rubella deaf was significantly below normal children with eight percent being retarded, and their academic achievement and communication skills were significantly below that of other deaf children. The rubella affected children were often characterized by a single basic syndrome which involved extensive hyperactivity, distractibility and difficulty in remembering, sometimes accompanied by explosiveness and uncontrolled emotionality. Vernon suggests that many of these problems have their basis in central nervous system dysfunction that is additional to the auditory impairment. 46 Graham and Rutter (1968) suggest that the presence of a chronic sensory handicap per se was not a crucial factor in the development of childhood psychiatric disorders, nor was the severity of the handicap nor its visibility a determining influence. Rather, the presence of dysfunction specifically of the brain was the crucial factor in the development of psychiatric disorder.
Wright (1971) writes that mental retardation occurs in infants suffering from the rubella syndrome when rubella virus infects cells of the brain, causing cell death and slow cell growth, which ultimately results in a small brain incapable of functioning optimally. Perhaps the varying behavioral characteristics found in the rubella children by investigators are ultimately to be explained by the presence or absence of central nervous system damage in a particular child. Knowledge of the action of rubella virus and the behavioral sequelae make such conclusion almost inescapable.
The most comprehensive work on psychiatric disorders in children with maternal rubella has been the study done by Chess, Korn and Fernandez (1971). Their book has been a source of a number of conclusion. This study involved 243 children who suffered as a result of the rubella epidemic 47 and had confirmed diagnoses of congenital rubella. The children had rubella related defects including visual, hearing, neurological and cardiac involvements. Psychiatric diagnoses included cerebral dysfunction, reactive behavior disorders, autism, partial syndrome of autism, and mental retardation of varying severity. It was noted that from the point of view of a youngster's risk of psychiatric disorder, a child whose mother had rubella during pregnancy has a fifty percent chance of having some type of behavioral disturbance. Of this population 3.3 percent had neurological and behavioral pathology and 15 percent of the children had reactive behavior disorders. Autism was considered in the category of childhood psychosis and schizopherenic adjustments. None of the rubella children gave evidence of a psychosis or childhood schizophrenia other than autism. The prevalence rate of autism in this sample would correspond to 412 per 10,000 for the core syndrome of autism and 329 per 10,000 for partial syndrome, yielding a combined figure of 741 per 10,000 as contrasted to the rate of 2.1 per 10,000 in the normal population. Children who were mentally retarded comprised the largest deviant sub-sample of the group. Ninety one youngsters or 37 percent of the total sample were retarded. In contrast in the normal population the incidence of mental retardation is 2-3 percent. There was also overlap of these 48 disorders in the sub-samples many of whom also had physical defects.
"Out of ten autistic rubella children studied, nine had varying degree of mental retardation. Of the eight who had partial syndrome of rubella, only one was not retarded while the remainder had additional symptoms of cerebral dysfunction. Kanner's basic criteria for autism had been used for the diagnoses, especially the "extreme autistic aloneness", language abnormalities, stereotypic relations to the environment. The lack of affective human contact remained a primary sign. In discussing sensory defects, and affective behavior, particular care was taken to "differentiate between children whose "aloneness" directly reflected these handicaps and those whose affective was inherently disturbed. One cannot judge by peculiar mannerisms or ritualistic behavior, since these may be exhibited by children who are simply retarded or by both autistic and non autistic children with sensory lack. Generally it is assumed that mannerisms causing excitations of nerve endings, such as the photo stimulation of eyeball pressing or the vestibular stimulation of head shaking and of lying with head down, do not necessarily represent an actual preference for non-human over human relatedness. 49 Given a choice, these nonautistic children prefer people to things"(Chess et al. (1971),p. 114).
"It may be argued that the isolating effect of living in a world with muted light and muted or absent sound can play a part in creating interpersonal distance. Whether this is to be considered stress is unclear. Experimental deprivation of sensory experience in sensorily normal individuals has been stressful to the point of creating hallucinations. This finding, however, cannot be mechanically applied to our rubella children. The issue here is not of going from a world of stimulii to one deprived of sight and sound, but of having from birth experienced fewer stimulii than the child with normal visual and auditory function. Where visual remediation or auditory support has been provided, one notes a dramatic contrast in reports on autistic and nonautistic children. The latter, after a period of getting used to the devices, respond by spontaneously putting on glasses and hearing aids on arising in the morning, and removing them only on going to bed. The autistic children however does not respond in this fashion. With him it is particularly difficult to determine the degree of hearing impairment and to determine to what degree remediation is effective" (Chess et al. (1971) p. 116). 50
"Another significant difference between the autistic and nonautistic rubella children with sensory defects is the use they make of alternative, relatively intact modes of experiencing. Nonautistic youngsters whose only sensory lack is hearing are very alert to their surroundings through their other senses, especially exhibiting visual alertness and appropriate responsiveness. Children with multiple handicaps may also be markedly responsive, not only through residual sensory capacities, but also through seeking of affectionate bodily contact. Some are shy, some slow to warm up, some perhaps wary; but one is impressed by their readiness to respond to appropriately selected and carefully timed overtures. In contrast, the autistic children neither explore alternative sensory modalities nor manifest appropriate responsiveness. They form a distinct group whose distance from people cannot be adequately explained by the degree or combination of visual and auditory loss nor by the degree of retardation where this exists. Moreover, whether retarded or not, their affective behaviors do not resemble those of children of their obtained mental age— in fact, there is no mental age for which these behaviors are appropriate" (Chess et al. (1971) p. 117). 51 "The presence of sensory and cognitive defect does not in itself account for the number of rubella children who fulfill the criteria for autism...Nor does the degree of defect necessarily determine the affective contact achieved by the children. A severely retarded 3-year-old with severe hearing impairment may gurgle and kick in pleased response to being tickled. Yet a mildly retarded autistic with a 3- year-old with moderate hearing loss may endlessly manipulate the pieces of a puzzle, but acknowledge the presence of people only by poking their eyes with a toy" (Chess et al. (1971) p. 117).
"In the area of communication, also, the autistic children were different...the autistic youngsters differed basically from other sensorily impaired children in that they did not have a repertoire of gestures: they did not point; they did not pantomime; they were often absorbed in activities such as hand and head movements, sucking fingers, sucking clothes, and walking in circles."
"Other rubella children with profound hearing loss could not speak, but were able to communicate through gestures. They acted out, they pointed, they entered into a meaningful dialogue. Quite often they were extremely persistent about making sure that the other person had 52 really understood what they wanted to express. Their whole body seemed to expect tensely the right sign or action from the listener that would indicate comprehension; if they had doubts, they often repeated their gestures spontaneously."
"Whereas parents of autistic children talked about their child's inability to respond affectively— they often qualified their kisses as "mechanical"— the parents of nonautistic sensorily damaged youngsters said that, although the children could not talk, they were very affectionate and they and the parents derived mutual joy from this affection. Many of these children showed through meaningful actions their parents' likes and dislikes..." (Chess et al. (1971) p. 118).
The high prevalence of autism in children with congenital rubella raises the vexing question of the etiology of childhood autism. These data would appear to support the argument in favour of an organic etiology against other lines of inquiry particularly in the absence of evidence to support the psychogenic hypotheses, including the postulates of the schizopherenic mothers, or "refrigerator parents."Nor did genetic components appear implicated. Socio-economic and other familial factors have been disproven. Striking differences among the retarded 53 contradicts the speculation that autism is simply a variety of mental subnormality. Any sensory defect in itself cannot explain autism in view of profound differences between children with similar handicaps. It is reasonable to speculate that the common component in the autistic rubella children is brain damage. The common denominator is that all children were at risk for prenatal invasion of the central nervous system by the rubella virus.
ON MENTAL RETARDATION Mental retardation presents itself in so many forms, degrees, and conditions, from so many known and unknown causes, with so many questions unanswered, that it is difficult to say clearly: these are the children who are retarded and this is what they can do and this is what we can do for them, and this is how we can eliminate the problem. The American Association on Mental Deficiency defines mental retardation as a significantly sub-average general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period.
A number of genetic anomalies can be accompanied by mental retardation, the best known being Down's Syndrome 54 and phenylketenuria which is caused by a recessive gene. A host of pre- and post-natal factors can damage the central nervous system and result in mental retardation. Mental retardation is often associated with many known physical and other abnormalities. It can be found in autistic children, in children whose mothers have suffered maternal rubella, in children with cerebral palsy, minimal brain dysfunction, epileptics etc. A host of dysfunctions can accompany mental retardation: motor disabilities such as tremors, ataxias, rigidity, chorea, dystonia, athetosis, paralysis, spasticity; perceptual deficits, information processing deficits, dyslaxias; attentional disorders and hyperactivity; visual disorders such as nystagmus, strasbismus; language disabilities including articulation and stuttring; and various aphasias. Psychological history, strengths and weaknesses are not necessarily the same for all retarded children. The particular mix of retarded children and the severity of their involvement may produce research results that are markedly diverse.
However, mentally retarded children as a group present some fundamental process problems that are worth enumerating. This is generally termed as the intellectual deficit. It is not to be confused with the criteria of IQ scores and standardized tests for the content and meaning 55 of intelligence itself is a controversy in its own right. The intellectual deficit primarily involves the learning process and memory.
Learning in the mentally retarded children is slow and inefficient for a number of reasons. They are unable to assimilate or even pay attention to relevant cues necessary for simple learning. Discriminant learning is often impaired. The learning curve for children of normal intelligence rises quickly at first and then levels off. For retarded children, choices are no better than chance for a number of trials followed by rapid improvement. Mentally retarded children often do not attend to relevant aspects of the situation. They have strong initial preference for position which they persist in using in spite of being told that their choice is incorrect. Once they can break this irrelevant set, they can learn quickly. In a special sense, they are not slow learners but slow to catch on. The same failure to generate relevant hypothesis that mars discrimination learning affects complex problem solving. However, once they master mediational strategies, they can function efficiently. For some unknown reason the mentally retarded children fail spontaneously to utilize the abilities they possess. While mentally retarded children can be trained to do a specific problem, they 56 characteristically do not generalize to similar problems. It is as if each task is a new one which must be mastered in its own right. The impediment to learning is obvious.
For learning to take place, remembering is essential. Remembering is an active process. Mentally retarded children are different in this process due to lack of spontaneous rehearsal. If they are trained, their performance improves, but frequently they will not spontaneously use such aids. Remembering is improved if incoming information is organized in a meaningful manner. Both retarded and young normal children show little evidence of clustering or grouping. While retardates can be taught to do so, once again they fail to utilize this aid spontaneously. Certain aspects of memory are intact in retardates, as is the case with certain aspects of learning. Long-term memory, as contrasted with short term or immediate memory, is as good as it is in children with average intelligence if the degree of original learning is the same. And forgetting is no more rapid than in nonretardates.
A pervasive problem in both memory and learning, therefore, is the failure of the mentally retarded children to grasp the principle that regardless of the task, having 57 a plan is superior to having no plan. They passively respond to each stimulus as it comes their way, and what they are taught in one situation stays welded to that situation alone.
Visual impairment is a significant concern for mentally handicapped persons. Legal blindness is more than 200 times more frequent among mentally retarded children than among non handicapped children (Warberg, 1986). Twenty percent of severely visually impaired mentally retarded children show no visual perception of light or react visually to only very large objects although the eyes appear normal on examination. The presence of optic atrophy is twice as high among mentally retarded as among other blind children.
OVERLAP OF VARIABLES IN AUTISTIC, DEAFBLIND AND RETARDED CHILDREN USING BEHAVIORAL CHECKLISTS
The use of rating scales and diagnostic checklists for autism have provided objective measures for the clinicians. Parks (1983) , in reviewing available instruments for assessment of autistic children, writes that most scales seem to suffer from lack of demonstrated discriminant 58 and/or content validity. Of the Behavioral Rating Instrument for Autistic and other Atypical Children (BRIAAC) (Ruttenberg, Kalish, Wenar and Wolf 1977), she writes, that "the reported interrater reliability figures are high and the discriminations needed for scoring are trainable. A reliability study on the initial four scales BRIAAC was undertaken using student raters (Ruttenberg et al, 1966). Spearman rank correlation coefficients obtained for the four scales ranged from .85 to .88. All of these children had previously been diagnosed as autistic, so the findings of high reliability does not indicate the ability to diagnose accurately using BRIAAC ( Ruttenberg et al., 1966) . Reliability figures have also been reported by Wenar and Ruttenberg (1976). Seven different pairs of raters provided scores on 113 autistic children. The obtained correlation coefficients are high, ranging from .85 to .93 across eight scales. In examining internal consistency, obtained correlations of the eight BRIAAC scales ranged from .54 to .86, indicating a common element but also sufficient variation to support inclusion of each scale (Wenar and Ruttenberg, 1976). Factor analysis resulted in a single factor characterized as "resistance to realistic participation in various activities". A principal-component analyses yielded one factor accounting for 69% of the variance, with only the psychosexual development scale 59 failing to load sufficiently (Cohen et al., 1978). In its content validity, the BRIAAC does not rely on various diagnostic criteria for selection of items. The content and the organization of the levels of the BRIAAC scales were empirically derived from daily clinical notes on the behavior of autistic children in a day care center. Wenar and Ruttenberg (1976) report the use of an index of reproducibility indicating that, except for the psychosexual scale, the ordering of the behavioral levels corresponds to the progression actually seen in these autistic children. Adherence of other groups of autistic children to these patterns needs to be systematically investigated before conclusions can be drawn about the universality of the sequencing of autistic children's behaviors. Concurrent validity has been reported for the three of the eight sub-scales and the total score using clinicians ratings as the dependent variable. Validation of the other sub-scales is needed. Ranked BRIAAC scores on 26 autistic and atypical children have been compared with clinicians ratings from another child study center (Wenar and Ruttenberg, 1976). Significant correlations were obtained for the total scores on the BRIAAC, and the sub- scales of Vocalization, Expressive speech, Sound and speech reception, and Relationship when these were compared with clinician's rankings of disturbance. In addition, the 60 discriminating ability of the BRIAAC has yet to be clearly demonstrated. Although the scale is able to distinguish between autistic and mentally retarded children, no attempt has been made to include a group of other psychiatrically disturbed children for comparison. Perhaps the most important feature of the BRIAAC is the empirical derivation of its content from natural observations of a group of autistic children. Although the proposed sequencing of behaviors through progressive levels has yet to be replicated in a longitudinal study of autistic children, the use of actual clinical notes to construct the content of these levels is unique." (p. 264) (Also see description on instrument below for more on reliability and validity)
In pursuing the research strategy of understanding psychopathology within the developmental context, Wenar, Ruttenberg, Kalish and Wolf (1986) compared scores on the BRIAAC given to normal and autistic children. Empirical evidence was found for the DSM Ill's statement that certain autistic behaviors are not normal at any stage of development. Such findings were relevant to the continuity versus the discontinuous debate. The investigators presented data indicating significant differences between the development of normal infants as compared with that of autistic children. 61
Several researchers have initiated a wide range of studies investigating overlapping characteristics in populations identified as autistic, mentally retarded, emotionally disturbed and even deaf-blind. Krug, Arick, and Almond (1979) have developed the Autistic Behavior Checklist in order to differentiate autistic individuals from individuals diagnosed severely mentally retarded, deaf-blind, severely emotionally disturbed, or normal. Fifty-seven behaviors were selected from nine established autism instruments including the BRIAAC and grouped into five symptom areas: sensory, relating, body and object use, language, and social. Though the study investigated only validity and reliability issues, certain interesting findings have been reported in the variability and similarity of profile patterns of the populations explored, but the authors stress the need for further research. They caution that the behaviors on the checklist, when differentiating between autism and mental retardation, could be measuring the severity of involvement of the same pathology. No developmental patterns or discussions of the behavioral variables or intercomparisons of all the population groups except with autism have been made. The samples on this study included individuals 18 months to 35 years age. 423 had been diagnosed as mentally retarded, 254 62 as emotionally disturbed, 100 deaf-blind and 100 normal. They were compared to 62 individuals ranging from 3 years to 23 years of age who had been diagnosed as autistic. The 57 behavior descriptors after statistical analysis were grouped into 5 symptom ares: Sensory, relating, body and object use, language, and social and self-help. Analysis of variance of the diagnostic groups and autism, and a subsample of demographic breakdown at p=<0.0001 are listed below in Tables 1 and 2 as reported in Krug, Arick, and Almond (1979, p. 226) :
The Behavior Observation Scale (Freeman, Guthrie, Ritvo, Schroth, Glass and Frankel, 1979) has been analyzed for similarities and differences between autistic and mentally retarded children. The authors stress that in order to specify any objective criteria, it is necessary to determine which if any of the behaviors observed in the repertoire of autistic children are in fact unique to the syndrome, which are simply the result of maturation, and which result from the children's generally delayed 63 TABLE 1
F-ratios of behavior checklist symptom areas and total scores from diagnostic groups compared with autism Krug, Arick, and Almond (1979) (p. 226); p=<.oool
autistic Vs. autistic Vs. severely autistic Vs. severely autistic Vs. mentally deaf-blind emotionally normal Symptom area retarded disturbed Sensory 143.93 59.71 124.58 500.87 Relating 158.00 102.09 117.02 1000.40 Body and 188.98 74.98 65.01 415.76 object use Language 107.47 59.86 48.70 366.81 Social 99.25 52.59 13.92 441.69 Total 279.78 141.19 122.93 1043.18 64
TABLE 2
F-ratios of the total behavior checklist scores across a sample of demographic data of four diagnostic groups when compared with the diagnostic group of autism Krug, Arick, and Almond (1979) (p. 226): p=<.0001, except* where probability level p<.05 Demographic autistic Vs. autistic Vs. data severely severely subsample mentally autistic vs. emotionally autistic Vs. retarded deaf-blind disturbed normal Chronologi cal age groups < 4 years 56.87 26.35 15.69 40.90 5-7 years 56.07 42.01 5.82* 275.03 8-10 years 55.22 31.87 67.85 433.02 11-14 year 29.79 23.38 17.97 78.62 15-35 year 34.79 14.38 17.19 78.62 Language age group 0-12 mos 140.13 61.52 5.61* 14.92 1-2 years 76.02 37.44 16.50 3-5 years 102.80 32.42 27.64 93.61 65 development. This issue is further clouded by the fact that most autistic children are mentally retarded and that autistic children with testable IQs above 70 exhibit different behavioral symptoms and have different outcome than those children with testable IQs below 70 (Bartak and Rutter, 1976). On the 67 objectively defined behaviors, only 11 had significant differences between the two groups. A discriminant analysis of the data showed that two behaviors, "hand flapping (defined as moving hands, repetitively by sides) and "social smiles" (smiling at the examiner in room) could be used to classify 72% of the subjects (80% of the autistic, and 63% of the retarded) into their correct diagnostic group confirming the position that there is a great deal of overlap in behavior exhibited by children with syndromes of autism and mental retardation. This is not surprising since it is well documented that most autistic children are also mentally retarded (See Table 3).
Freeman, Ritvo, Guthrie, Schroth, and Ball (1978), stress the importance of including developmental parameters in diagnostic criteria for autism, particularly in children who present a picture that is ever changing as they grow older. Thus one must constantly reevaluate behaviors and symptoms with reference to psychological, physiological and 66
TABLE 3
Behaviors which differed significantly between autism and mental retardation
(Freeman, Guthrie, Ritvo, Schroth, Glass and Frankel, 1979) (P522) *P<.04 all others P=<0.01
Behavior Autistic Retarded t
Repeats Sounds .92 .54 2.69
Visual detail scrutiny .48 .29 2.35
Rubbing surfaces .68 .41 2.47
Hand flapping .19 .05 2.72
Whirling .08 .01 2.15
Posturing .35 .20 2.05
Eye contact 1.02 1.35 -2.7
Social smile .16 .40 2.75
Ignores examiner 1.76 1.33 2.54
Communicative speech .10 .26 2.46
Deviant ball play .02 .01 2.06 67 behavioral changes. In comparing normal, autistic and mentally retarded children, using the Behavioral Observation Scale, discriminant analysis indicates that communicative speech appears a major role in differentiating all the groups, but when comparing the retarded and the autistic group, there remains a great deal of overlap with little discrimination. A likely reason for the poor discrimination between the autistic and retarded group may be due to the fact that at least some of the behaviors being studied could be expected to depend on chronological or mental age. Developmental perspectives must be taken into consideration when diagnosing autism.
In an elaborate study of diagnostic agreement using clinical assessments and two behavior rating scales, The BRIAAC, and Rimland E-2 checklist, Cohen, Caparulo, Gold, Waldo, Shaywitz, Ruttenberg, and Rimland (1978) compared the responses of 27 children who had primary childhood autism (n=13), secondary childhood autism or autism associated with specific disorders (n=5), primary childhood or developmental aphasia (n=5), early childhood psychosis (n=2), or mental retardation (n=2). Three types of hypotheses were explored: the relations between diagnostic systems in differentiating diagnostic groups; the relations 68 between systems in rank ordering individual children on the single dimension of severity of the disorder; and the reliability of different behavioral dimensions of disorder in differentiating children. Comparisons of the diagnostic methods and of the diagnoses are presented in Table 4. The BRIAAC aims at describing competence regardless of the differences in natural history, etiology, or other types of environmental biological or psychological variance. The BRIAAC and clinical ratings of dimensions of current behavior and global severity were in high agreement. There were suggestions from the BRIAAC profiles of differences between clinically defined diagnostic groups. The BRIAAC scores, however, did not delineate different subgroups. The mean BRIAAC scores for all groups on each scale was markedly below 100, the value received by normal 4-year-old children. Of special interest are the areas of comparative competence and disability within and between groups. Aphasic children, for example, received the highest scores of the entire population on the vocalization scale, a finding which is consistent with clinical impressions. Also in agreement with clinical impressions is the observation that the children with primary autism received the lowest score of the five groups on relationship, while aphasic children scored the lowest on the mastery scale, with the 69 group of mentally retarded children receiving the highest score.
In this same study, principal component factor analysis performed on the eight BRIAAC scales revealed one major factor accounting for 69% of the variance, on which all the scales except psychobiological development were highly loaded. The BRIAAC principal factor has been theoretically interpreted as reflecting a child's motivation to be engaged with reality or the presence of some undefined processing dysfunction (Parks, 1983). More realistically this factor may be defined as a general "severity of disturbance" dimension. The distribution of cumulative scores by diagnostic group reveals that most of the children with a clinical diagnosis of primary childhood autism had scores between 300 and 400, out of a maximum of 800. The children with secondary autism were within this range, while those with aphasia tended to be in the higher part of the range. The individuals in the psychotic and mental retardation groups were quiet different from each other and were roughly in the same range as other children. Thus broadly speaking, the cumulative scores for the different diagnostic groups were all consistent with a generally equivalent degree of disability. If autism were defined on the basis of the cumulative score alone, no 70 clear discrimination would be suggested between diagnostic groups defined by the clinical evaluations. To assess intermethod reliability in diagnosis, the clinical ratings were rank ordered and correlated with the scores independently derived from three BRIAAC scales, and with the cumulative score. The two methods significantly agreed on all four measures: social relationship, r=.83, p <.001; expressive language, r=.45, p <.02: receptive language, r=.37,p <.05; and global severity, r=.63, p <.001.See Table 4 below of BRIAC group means and standard deviations (Cohen et al., 1978 p.696) Wolf, Wenar, and Ruttenberg, (1972) present a comparison of personality variables in autistic and mentally retarded children. In this study, personality characteristics of 35 severely mentally retarded children, including 11 with Down's Syndrome, and 32 autistic children evaluated on the basis of the Behavior Rating Inventory for Autistic Children were compared and discussed. The children, 48 boys and 19 girls, ranged in age from 4 to 12 years. Rating on the five scales pertaining to the nature and degree of relationship to an adult as a person, communication, vocalization, and expressive speech, drive for mastery, and psychosexual development indicated that the severely retarded group scored significantly higher in each area. Also higher for that group were the correlations 71 between various scales. It is suggested that severely retarded children, particularly those with Down's syndrome, are less disturbed and better integrated than autistic children, and that fragmentation, compartmentalization and lack of generalization between key areas of function are specific factors in the autistic processing. Correlations for the mentally retarded group ranged from .54 to .84, and those for the autistic group from .03 to .57. Children with Down's syndrome were strikingly advanced in all areas. The other mentally retarded children, while superior in relationship, communication and vocalization were not significantly different from the autistic in mastery and psychosexual development. 72
TABLE 4 BRIAAC means in various pathologies (Cohen et al. 1978) Relation Communica Mastery Vocaliza Sound and ship tion tion speech primary 50.0 mean 45.5 37.3 43.2 60.7 autism n 13 9.9 SD 16.2 16.5 20.6 20.7 Secondary 51.0 52.2 39.4 51.0 69.0 autism n 5 12.9 12.0 24.1 13.1 19.7 Aphasia n 5 67.2 67.0 63.6 70.8 77.2 14.0 8.5 15.7 18.9 15.2 Psychosis n 2 52.5 62.0 42.0 64.5 82.5 (45, 60) (52, 72) (70, 14) (69, 60) (65, 100) Retardation 67.0 55 82.0 55.0 65.5 n 2 (86, 48) (79, 40) (71, 93) (90, 20) (96, 35)
Social Body Psysexual Cumulative Function Movement develop Total primary 51.6 mean 53.8 42.4 383.3 autism n 13 18.6 SD 15.3 8.9 89.4 Secondary 52.6 61.0 48.8 425.2 autism n 5 24.0 23.6 11.9 129.1 Aphasia n 5 67.4 78.4 52.6 544.2 20.5 11.2 15.4 83.8 Psychosis n 2 69.5 71.0 45.5 489.5 (45, 94) (82, 60) (43,47.5) 384 594.5 Retardation 61.0 63.5 48.75 485 n 2 (85, 37) (88, 39) (37.5,60) 666,304.5 73
HYPOTHESES The research strategy involved comparing low functioning deaf-blind and autistic children for variables assessed by the Behavioral Rating Instrument for Autistic and other Atypical Children. Mentally retarded, non autistic children served as a control for mental retardation in the low functioning deaf-blind group. The development of the low functioning deaf-blind children was also compared with that of normal infants/toddlers. The questions addressed are:
1. Is there evidence that the overall degree of disturbance as measured by the BRIAAC is the same in low functioning deaf-blind and autistic populations?
Null Hypothesis 1: There are no significant differences in the overall degree of disturbance as measured by the BRIAAC in the low functioning deaf-blind and autistic populations at p = > 0.01
2. Is there evidence that the component behaviors comprising BRIAAC are equally affected in the low functioning deaf-blind and autistic children or is there a 74 difference in the patterning of these components? In the latter case, what is the nature of the different pattern?
Null Hypothesis 2: There are no significant differences in the component behaviors comprising the BRIAAC in the low functioning deaf-blind and autistic children at p = > 0.01.
3. Is the developmental progression within the components of BRIAAC the same in low functioning deaf-blind children as it is in autism? If not then what is the nature of differences in progression?
Null Hypothesis 3: There are no significant differences in the developmental progression within the components of the BRIAAC in the low functioning deaf-blind and autistic children.
4. Is there evidence of a qualitative difference in the development of low functioning deaf-blind children when compared with normal children, as there is when autistic children are compared with normal children (Wenar, et al., 1986)? 75 Null Hypothesis 4: There are no significant qualitative differences in the development of low functioning deaf-blind children when compared with normal children. CHAPTER III
METHODOLOGY
Population:
BRIAAC scores for low functioning children who are both deaf or severely hearing impaired and blind or severely visually impaired were obtained in an extensive project directed by Schein (1981). The population came from six day and eight residential programs providing services to deaf-blind children. The programs covered a wide geographical area. Over 70 deaf-blind children ranging from ages 5 to 13 years were tested and retested between 1978 and 1981. They generally functioned below accepted standards for their chronological age in most developmental areas. Most of the children functioned below average intelligence, as a group were severely or profoundly deviant in sensory, motor, cognitive, affective areas, and 63 had other handicaps including cardiac, cerebral palsy, emotional etc. Many of these children had autistic type behaviors such as withdrawal, lack of affect, inability or disinclination to relate to others, self-abuse, self- stimulation, and perseveration. Others showed acting out
76 77 behaviors directed towards peers and adults. Their language communication abilities ranged from lack of any specific, consistent use of gestures, signs, or sounds through use of single or multiple signs or words in some appropriate verbal system. Most of them communicated nonverbally.
Wolf-Schein, (1988) in a position paper, describes the low-functioning as a term that is widely used in a general way to indicate a group of individuals that are severely or profoundly deviant in any sensory, motor, cognitive, affective area. There are no specific parameters to what this means except those described by the administrators of a particular program serving that population. In collecting data for the above deaf-blind population the term was used as follows: all students from which this sample population is derived had significant enough hearing and visual losses that they were considered deaf-blind. In addition, as a group they had a multitude of other severe problems, in different combinations and of different degrees with the total effect causing them to be extremely dependent on others in all areas. The term dependent is used in some programs to indicate that, whatever the handicap, it is of an extreme degree and the individual so-called needs consistent and intensive help. The above population did require constant attention to learn and a significant 78 amount of physical support to survive. What is more, unlike the normal infant who is expected to evolve into a fully independent person, this population would improve very slowly and only with much support.
only 46 deaf-blind children's scores from the above study were utilized based upon age criteria and availability of their actual test protocols and medical histories. Their ages ranged from 5 to 12 years. Of these 46 children, 20 were girls and 26 boys. 31 children of the 46, 14 females and 17 males had confirmed diagnoses of congenital rubella. The other 15 were classified as non- rubella deaf-blind and had various etiologies like retrolental fibroplasia, optic atrophy, meningeocephalitis, and other undetermined causes. There were 6 girls and 9 boys in this group. The groups were separated into rubella and non-rubella deaf-blind to provide a comparison group of homogeneous etiology. See Table 5 regarding population spread by age and sex. Evaluation of daily notes taken with the BRIAAC protocols indicate that almost all of the children functioned below accepted standards for their chronological age in most developmental areas, and as a group were severely or profoundly deviant in sensory, motor, cognitive, and affective affective areas. 79
TABLE 5
Age and sex distribution of deaf-blind group 20 females and 26 males
Age Group N M F 5 6 7 8 9 10 11 12 Rubella 31 17 14 2 6 2 4 6 6 4 1
Retrolental 4 3 1 2 1 1 Fibroplasia Meningitis 2 2 1 1
Optic Nerve 1 1 1 Colombas Cerebral palsy 1 1 1 Optic atrophy Cortical 1 1 1 impairment Detached retina 1 1 1
Hydrocephalic 1 1 1
Spinabifida 1 1 1
Undetermined 3 2 1 2 1 80 Schien (1981) report two new supplementary scales for the BRIAAC in terms of manual gesturing and signing to be used with deaf blind populations or other atypical populations who may fail to communicate verbally. The scores of these have not been used in this study.
Interrater reliability of the scores on the deaf-blind population used in this study yield high correlations. All correlations are significant beyond p=.01. The correlations are: relationship, .98; communication, .91; drive for mastery, .94; vocalization, .80; sound and speech, .85; body movement, .90; social responsiveness, .98; psychobiological, .84; and cumulative total score, .96.
Schein (1982) report correlations between BRIAAC subscales and degrees of visual and auditory impairment. The correlations for visual impairment are: relationship, - .29; communication, -.27; drive for mastery, -.37; vocalization, -.20; sound and speech, -.20; body movement, -.31; social responsiveness, -.35; psychobiological, -.34; and cumulative total score, -.31. All are statistically significant except vocalization and sound and speech. The correlations between BRIAAC subscales and degree of auditory impairment are less significant: relationship, .12; communication, .16; drive for mastery, .20; 81 vocalization, -.14; sound and speech, -.29; body movement, .09; social responsiveness, .22; psychobiological, .17; and cumulative total score, .23.
The data on autistic children came from scores of subjects who were part of various reliability and validity studies of the BRIAAC (Ruttenberg, Kalish, Wenar and Wolf 1977) 34 children, ranging from age 5 to 12 years were diagnosed as autistic strictly based upon Kanner's original criteria. These children came from 20 institutions with diverse programs. Of these 34 children, 21 were boys and 13 were girls. Children with evidence of severe organic impairments or other developmental deviations were excluded from the autistic group. Most of these children were regarded untestable so no specific IQ scores were available. However they did not seem to be severely mentally retarded. (See Table 6 below for age and sex distribution).
TABLE 6
Age and sex distribution of the autistic group 13 females and 21 males Age Group N M F 5 6 7 8 9 10 11 12 AUTISTIC 34 21 13 1 6 5 1 12 7 1 1 82
BRIAAC data on mentally retarded children came from a study by Wolf, Wenar and Ruttenberg (1972) This group comprised of 23 boys and 12 girls whose ages ranged from 4 to 10 years. It was defined primarily on the basis of standardized test scores, and clinical diagnoses conforming with either those of American Medical Association or the American Association on Mental Deficiency. Raters' descriptions of these children indicated extreme deficits in intellectual functioning as well as adaptive behavior. Except for one, all in the MR group were ambulatory. Eleven children in this group, 8 boys and 3 girls, had been afflicted with Down's Syndrome while the remaining 24 had a variety of diagnoses: encephalopathy, chronic brain syndrome, RH incompatibility, mechanical brain injury, cerebral atrophy, and epilepsy (see Table 7).
Data on the infant population came from a comparative study of the normal and autistic children (Wenar, Ruttenberg, Kalish and Wolf, 1986) . This study utilized normal children's scores from two studies, the first conducted by Kalish (1976), and the second conducted at the Developmental Center for Autistic Children (DCAC). A total of 275 normal children ranging in age from 3 months to 36 83 months were involved in this study. The children were selected from different schools, day care centers, and nursery programs in which settings they all had been judged by staff as functioning normally for their chronological age. The developmental progression patterns of the deaf- blind will be compared to those derived in this study of normal children, 3 months through 36 months of age.
Comparability of Populations
The deaf-blind, autistic, and mentally retarded populations have been equated for age. For the purpose of this study, a low functioning person is one over the age of five, who for any reason has the majority of behaviors on level 7 or below on the BRIAAC scales, with the total score on each scale below 75. The top score on each scale is 100 and represents behavior of a normal 3 to 4-year old. Even if the children have some behaviors on higher levels, these are infrequent or inconsistent or counterbalanced by a preponderance of developmentally low behaviors. 84
TABLE 7
Age, sex and etiological distribution of mentally retarded group 12 females and 23 males Wolf, Wenar and Ruttenberg (1972) (p 96) Age Group N M F 5 6 7 8 9 10 11 12 Down's Syndrome 11 8 3 1 3 1 3 3
Encephalopathy* 9 5 4 median age 9.4
Chronic brain 2 1 1 median age 7 . 3 syndrome RH 2 2 median age 8.7 incompatability mechanical brain 1 1 1 injury Cerebral atrophy 1 1 1
Routhmund 1 1 1 Thompsonsyndrome Froelich's 1 1 1 syndrome Epilepsy 1 1 1
Structural 1 1 1 reactionManifest Undetermined 5 4 1 median age 8.1 85 Instrument: Behavior Rating Instrument for Autistic and other Atypical Children or BRIAAC
The instrument utilized was the Behavior Rating Instrument for Autistic and other Atypical Children or BRIAAC (Ruttenberg et al.,1977). As its name implies, BRIAAC assesses the autistic/atypical child's ongoing behavior in familiar settings, such as the home or institution. Its eight component scales evaluate relationship to a familiar adult, communication, drive for mastery, vocalization and expressive speech, sound and speech reception, social responsiveness, body movement, and psychobiological development. Each scale has 10 levels ranging from the most profoundly deviant and infantile behaviors to behaviors that begin to approach those characteristics of the normal 3- to 4-year olds. After observing the child for l1/2 to 2 hours, the rater distributes 10 points among 10 levels of each scale, according to proportionate amount of behavior the child showed at the various levels. The total score for a scale is obtained by multiplying the level by the points assigned and summing the resulting products. Thus, the scores can range from 10 to 100. 86 The levels within scales were originally based on longitudinal data from a population of 29 autistic children attending what is now called Center for Autistic Children. Both the staff and child care workers made daily behavioral notes and each child was evaluated at weekly staff meetings. A minimum of 4 years worth of observational notes were available on each child and these notes provided the basic data on which the levels were constructed. Obviously the entire population did not progress from the lowest to the highest levels; rather, the scales represent a composite of the group's progression. The children in this original population ranged from 3 and 8 years age.
A resume of the eight scales is presented: Relationship. This scale begins with imperviousness to people; at subsequent levels the child attends briefly to an adult at close range, then sustains close physical proximity, and finally, shares experience, and is empathetic and accommodating. Communication. At the lowest level the child shows no sign of directing behavior toward another person; at subsequent levels the child directs requests for help or attention toward a specific person, develops regular patterns of approach and rejection, and finally, communicates ideas and feelings. 87 Mastery. This scale begins with a pathological need for sameness and progress from a momentary interest in exploring objects through increased initiative to sustained, goal oriented activity. Vocalization. Initially the child is essentially non vocal; at the higher levels musical babbling, imitation, and then jargon develop until finally, the child can use a sentence of more than three words. Speech and Sound Reception. The lowest level involves a complete obliviousness to sound; next comes an awareness of sounds and words, until finally, the child understands simple sentences. Social Responsiveness. The child initially is oblivious to demands for socially acceptable behavior in regard to eating, toileting, dressing, etc., gradually becoming interested, cooperative, and intrinsically motivated to behave appropriately. Body Movement. Initially the child's body is either like a "dead weight" or a blob, or the child's body is rigid and locomotion has a driven quality. In either case, the children progress to the point where they have the normal repertoire of movements.
Psychobiological Development. This scale charts the progress from total concentration on bodily sensations (e.g. rocking) and primitive expressions of affect (e.g. 88 rage) to socially acceptable personality characteristics and socially appropriate expression of affect.
The BRIAAC manual describes a standardized method of observing children, and rating and scoring their behaviors. The reliable use of the BRIAAC requires both understanding of the scales and skilled observation and a period of supervised training and a thorough knowledge of the manual.
All the scores in this study were obtained from observers who had received extensive training in order to ensure compatibility of ratings. A minimum of two hours of observation must be completed before scoring is done. The observation must be unobtrusive and should take into consideration information from informants or care takers whether or not the day has been a usual one. If a child's behavior has been unusual, the ratings must not be changed. However the departure from typicality should be noted and if essential, the child must be re-rated. Only observed behavior is scored. The rater should never score on the basis of what he infers the child would have done had the situation been different or what he believes the child is capable of doing. 89 Experimental Design: This study is based upon data that was collected many years earlier. The fact that archival data is being used makes this study more of a quasi experiment rather than a true experiment. An ex post facto multifactorial design has been employed. The independent variables are attributes rather than active variables and are the four diagnostic categories of autistic, rubella-deaf-blind, non-rubella deaf-blind and mentally retarded. The dependent variables are the cumulative BRIAAC scores and BRIAAC scores on each of the eight scales. The children's ages and sex are also compared within each diagnostic group as the independent variables with the BRIAAC scores as the dependent measures. CHAPTER IV
RESULTS The results have been laid out in seven sections: 1) basic group statistics; 2) within group comparisons for age and sex effects; 3) three overall MANOVAs comparing all diagnostic groups; 4) eight two group ANOVA comparisons; 5) posteriori multiple comparisons of means using Tukey's (HSD) test; 6) intercorrelations for group internal consistancy; 7) Leik and Matthews scalogram analyses.
(1) Basic statistics including means and standard deviations for autistic, deaf-blind, rubella deaf- blind, non-rubella deaf-blind, and mentally retarded groups on the various behaviors tapped by the BRIAAC are presented on tables 8, 9, 10, 11, and 12. Figure 1 is a plotting of the mean scores on the BRIAAC scales for these groups. All groups had mean scores below 100. These results show more overall severity of disturbance in deaf-blind children than in the autistic children. The mentally retarded children scored well above autistic and deaf-blind children. Of all the groups the rubella deaf-blind seem to have
90 91 suffered the most disturbance particularly in vocalization and in sound and speech.
TABLE 8
Basic statistics: autistic children Total number of children 34: Age range 5-12 years Relation Communi Drive for Vocaliza Sound & ship cation Mastery tion Speech Minimum 20.00 14.00 0.00 10.00 25.00 Maximum 87.00 100.00 96.00 100.00 100.00 Mean 44.85 41.76 41.41 37.20 60.32 Stndard Dev 18.84 20.24 22.72 27.89 21.39
Social Body Psychobio Respons. Movement logical Total Minimum 28.00 27.00 13.00 34.00 Maximum 98.00 100.00 74.00 707.00 Mean 52.82 55.23 41.26 364.79 Standard Dev 18.56 20.58 13.74 148.98 92 TABLE 9
Basic statistics: deaf-blind children Total number of children 46: Age range 5-12 years Relation Communi Drive for Vocaliza Sound & ship cation Mastery tion Speech Minimum 21.00 13.00 15.00 11.010 "b" Maximum 78.00 70.00 77.00 64.00 73.00 Mean 42.44 34.41 38.87 24.78 31.35 Stndard Dev 12.93 12.44 13.24 12.71 20.80
Social Body Psychobio- Total Respons. Movement logica Minimum 20.00" 18.00" 16.50" 176.00 Maximum 79.00 80.00 75.50 549.50 Mean 39.67 39.50 38.94 291.38 StandardDev 12.42 14.82 12.63 80.76
TABLE 10
Basic statistics: mentally retarded children Total number of children 35: Age range 5-12 years Relation Communi Drive for Vocaliza Psychobiol ship cation Mastery tion ogical Minimum 35.o"o 2Q.o"o' 14.o"b" IO.O'O' 25.o"o Maximum 90.00 83.00 85.00 106.00 201.00 Mean 66.00 53.09 50.17 49.86 97.45 Standard 14.89 16.01 25.47 30.82 50.18 Deviation 93 TABLE 11
Basic statistics: deaf-blind rubella children Total number of children 31: Age range 5-12 years Relation Communi Drive for Vocaliza Sound & ship cation Mastery tion Speech Minimum 21.00 13.00 15.00 11.00 0.00 Maximum 78.00 68.00 77.00 43.00 65.00 Mean 42.07 34.39 39.03 20.13 24.94 Standard 13.76 13.03 12.98 7.14 17.62 Deviation
Social Body Psychobiol Total Respons. Movement ogica Minimum 20.00 18.00 22.00 176.00 Maximum 79.00 80.00 75.50 549.50 Mean 40.26 40.94 39.30 282.30 Standard 12.71 14.08 12.11 76.17 Deviation
TABLE 12
Basic statistics: non-rubella deaf-blind children Total number of children 15: Age range 5-12 years Relation Communi Drive for Vocaliza Sound & ship cation Mastery tion Speech Minimum 30.00 24.00 19.00 12.00 10.00 Maximum 65.00 70.00 73.00 64.00 73.00 Mean 43.20 34.47 38.53 34.40 44.60 Standard 11.45 11.54 14.21 16.22 21.11 Deviation
Social Body Psychobiol Total Respons. Movement ogica Minimum 24.00 19.00 16.50 193.00 Maximum 71.00 77.00 75.00 505.00 Mean 38.47 36.53 38.17 310.13 StandardDev 12.12 16.34 14.05 89.29 94
O Autistic D deaf blind A retarded O rubella + non rubella
M S-S S-R BM
BRIAAC SCALES KEY: R— relationship, C— communication, M— drive for mastery V— vocalization, S-S— sound and speech reception, S-R— social responsiveness, BM— body movement, P— psychobiological
FIGURE 1
Plot of mean scores on the BRIAAC scales for autistic, rubella deaf-blind, non-rubella deaf-blind and mentally retarded children 95 Before analyzing the diagnostic groups to test the hypotheses of the study, age and sex effects were analyzed to determine if these covariate in the diagnostic groups across the BRIAAC scores. The autistic, rubella deaf-blind and non-rubella deaf-blind groups were analyzed to see if there were any age or sex related differences in these groups. Univariate analyses of variances were thus computed with age and with sex as the independent variables, and the component BRIAAC scales and the total cumulative scores as the dependent variables in each group. The results of these analyses are presented as follows in the six ANOVA tables:
Age related differences:
(a) Autistic children (see table 13) : The overall F-statistic of 1.035, and Wilk's lambda of 0.720 are significant only at P = 0.44 indicating that there are no significant differences in the scores of various BRIAAC components in the autistic group in terms of age. The univariate P values for each scale are > 0.01. Therefore in the autistic group whose ages ranged from 5 to 12 years, the BRIAAC 96 scales and the cumulative score are not related to the age of the child
TABLE 13
Autistic children: age effects (34 children) Analysis of variance VARIABLE SS DF MS F P Relat 726.70 1 726.74 2.115 0.156 error 10995.52 32 343.61 Comm 301.99 1 301.99 0.731 0.399 error 13220.12 32 413.12 DrvMst 68.00 1 68.00 0.128 0.723 error 16968.233 32 530.25 Vocal 3294.84 1 3294.84 4.712 0.037 error 22376.71 32 966.27 Snd Speech 318.84 1 318.84 0.690 0.412 error 14786.59 32 462.08 Soc. Respon 536.327 1 536.32 1.583 0.217 error 10838.614 32 338.707 Body Mvt 1781.861 1 1781.86 4.676 0.038 error 12194.25 32 381.07 Psybio 738.47 1 738.47 4.0301 0.046 error 5494.13 32 171.69 Total 29400.41 1 29400.41 1.338 0.256 error 703021.14 32 21969.41 MULTIVARIATE TEST STATISTICS Wilk's Lambda= 0.720 F-Statistic=1.035 DF= 9, 24 PROB= 0.44 97 Rubella deaf-blind children (see table 14): The overall F statistic of 2.194, and a Wilk's lambda of 0.515 are only significant at P = 0.06 indicating that there are no significant differences in the scores of various BRIAAC components in the rubella deaf-blind group in terms of age. The univariate P values for each scale are > 0.01. Therefore in the rubella deaf- blind children whose ages ranged from 5 to 12 years, the scores on the BRIAAC scales and the cumulative score are not related to the age of the child.
Non-rubella deaf-blind children (see table 15): The overall F statistic of 0.695, and a Wilk's lambda of 0.458, P = 0.72, indicating that there are no significant differences in the scores of various BRIAAC components in the non- rubella deaf-blind group in terms of age. The univariate p values for each scale are >0.01. Therefore, in the rubella deaf-blind children whose ages ranged from 5 to 12 years, the scores on the BRIAAC scales and the cumulative score are not related to the age of the child. 98
TABLE 14
Rubella deaf-blind children: age effects Total 31 children Analysis of variance VARIABLE SS DF MS F P Relat 22.52 1 22.52 0.117 0.735 error 5599.86 29 193.09 Comm 130.63 1 130.63 0.788 0.382 error 4809.30 29 165.83 DrvMst 67.12 1 67.12 0.404 0.530 error 4823.71 29 166.33 Vocal 62.75 1 62.75 1.247 0.273 error 1459.11 29 50.31 Snd Speech 9.26 1 9.26 0.028 0.867 error 9464.15 29 326.35 Soc. Respon 170.92 1 170.92 1.095 0.304 error 4528.43 29 156.15 Body Mvt 164.80 1 164.80 0.795 0.381 error 6042.87 29 208.37 Psybio 148.48 1 148.48 1.041 0.316 error 4135.01 29 142.58 Total 931.48 1 931.48 0.156 0.695 error 172718.72 29 5955.81 Multivariate statistics Wilk's Lambda=0.515 F-Statistic=2.194 DF= 9, 21 PROB= 0.06 99
TABLE 15
Non-rubella deaf-blind children: age effects Total 15 children Analysis of variance VARIABLE SS DF MS F P Relat 91.66 1 91.66 0.66 0.431 error 1806.06 13 138.92 Comm 353.18 1 353.18 2.77 0.120 error 1657.74 13 127.51 DrvMst 220.24 1 220.24 1.036 0.327 error 2764.16 13 212.62 Vocal 18.55 1 18.55 0.067 0.800 error 3615.17 13 278.09 Snd Speech 257.90 1 257.90 0.683 0.424 error 4911.02 13 377.77 Soc. Respon 358.09 1 358.09 2.543 0.135 error 1830.30 13 140.79 Body Mvt 131.77 1 131.77 0.498 0.493 error 3439.55 13 264.58 Psybio 37.79 1 37.79 0.174 0.683 error 2821.63 13 217.04 Total 4197.50 1 4197.50 0.505 0.490 error 107977.43 13 8305.95 MULTIVARIATE TEST STATISTICS Wilk's Lambda= 0.458 F-Statistic=0.659 DF= 9, 5 PROB= 0.72
(ii) Sex related differences: (a) Autistic children (see table 16) : The overall F-statistic of 1.645, and Wilk's lambda of 0.618 are significant only at P = 0.15 100 indicating that there are no significant differences in the scores of various BRIAAC components in the autistic group in terms of sex differences. The univariate P values for each scale are > 0.01. Therefore in the autistic group the scores on the BRIAAC scales and the cumulative score are not related to the sex of the child.
TABLE 16
Autistic children: sex effects Total 34 children Analysis of variance VARIABLE SS DF MS F P Relat 0.001 1 0.001 0.000 0.999 error 11722.26 32 366.32 Comm 24.61 1 24.61 0.058 0.811 error 13497.50 32 421.79 DrvMst 332.20 1 332.20 0.636 0.431 error 16704.02 32 522.00 Vocal 50.84 1 50.84 0.108 0.744 error 15054.59 32 470.45 Snd Speech 46.36 1 46.36 0.131 0.72 error 11328.57 32 354.01 Soc. Respon 275.80 1 275.80 0.644 0.428 error 13700.31 32 428.13 Body Mvt 328.05 1 328.05 0.414 0.524 error 25343.50 32 791.98 Psybio 692.33 1 692.33 3.999 0.054 error 5540.28 32 173.13 Total 5065.55 1 5065.55 0.223 0.640 error 727356.00 32 22729.87 MULTIVARIATE TEST STATISTICS Wilk's Lambda= 0..618 F-Statistic=1.645 DF= 9, 24 PROB= 0.15 101
(b) Rubella deaf-blind children (see table 17):
The overall F-statistic of 1.515, and Wilk's
lambda of 0.606 are significant only at P = 0.20
indicating that there are no significant
differences in the scores of various BRIAAC
components in the rubella deaf-blind group in
terms of sex differences. The univariate P
values for each scale are > 0.01. Therefore in
the autistic group the scores on the BRIAAC
scales and the cumulative score are not related
to the sex of the child.
(c) Non-rubella deaf-blind children (see table 18) :
The overall F-statistic of .715, and Wilk's
lambda of 0.437 are significant only at P = 0.68
indicating that there are no significant
differences in the scores of various BRIAAC
components in the non-rubella deaf-blind group
in terms of sex differences. The univariate P
values for each scale are > 0.01. Therefore in
the autistic group the scores on the BRIAAC
scales and the cumulative score are not related
to the sex of the child. 102
TABLE 17
Rubella deaf-blind children: Sex effects Total 31 children Analysis of variance VARIABLE SS DF MS F P Relat 0.488 1 0.488 0.033 0.960 error 5621.89 29 193.85 Comm 120.27 1 120.27 0.724 0.402 error 4819.66 29 166.19 DrvMst 36.36 1 36.36 0.217 0.645 error 4854.47 29 167.39 Vocal 274.45 1 274.45 6.381 0.017 error 1247.41 29 43.01 Snd Speech 1849.50 1 1849.50 7.035 0.013 error 7623.91 29 262.89 Soc. Respon 475.48 1 475.48 3.26 0.081 error 4223.87 29 145.65 Body Mvt 12.19 1 12.19 0.057 0.813 error 6195.47 29 213.63 Psybio 91.47 1 91.47 0.633 0.433 error 4192.03 29 144.55 Total 8545.88 1 8545.88 1.0501 0.230 error 165104.32 29 5693.25
MULTIVARIATE TEST STATISTICS Wilk's Lambda= 0.489 F-Statistic=4.534 DF= 9, 21 PROB= 0.02 103
TABLE 18
Analysis of variance Non-rubella deaf-blind children: sex effects Total 15 children VARIABLE SS DF MS F P Relat 52.900 1 52.90 0.373 0.55 error 1844.833 13 141.910 Comm 141.878 1 141.878 0.987 0.33 error 1869.056 13 143.774 DrvMst 98.178 1 98.178 0.442 0.51 error 2886.22 13 222.017 Vocal 253.344 1 253.344 0.974 0.34 error 3380.389 13 260.030 Snd Speech 677.878 1 677.878 1.962 0.18 error 4491.056 13 345.466 Soc. Respon 184.90 1 184.90 1.200 0.29 error 2003.50 13 154.115 Body Mvt 71.111 1 71.111 0.264 0.61 error 3500.222 13 269.248 Psybio 1.600 1 1.60 0.007 0.93 error 2857.83 13 219.833 Total 70.225 1 70.225 0.008 0.92 error 112104.708 13 8632.439
MULTIVARIATE TEST STATISTICS Wilk's Lambda= 0.437
F-Statistic=0.719 DF= 9, 5 PROB= 0.6 104
In order to test the hypothesis 1 whether there are any significant overall differences in the degree of disturbance in the autistic, deaf-blind and mentally retarded groups, three overall multivariate analyses of variance and discriminant analyses were computed: In the first MANOVA autistic, deaf-blind and mentally retarded children were compared on only five scales since scores on all eight scales for mentally retarded children were not available. In the second MANOVA the deaf-blind were further grouped into rubella deaf- blind and non-rubella deaf blind to further assess differences on the five BRIAAC scales. The third MANOVA was computed on the full eight scales of the BRIAAC for the autistic, rubella deaf-blind and non- rubella deaf-blind children. The mentally retarded group was not included in this MANOVA because of the lesser number of scales used for this group. Significant differences indicated on the MANOVAs are then further analyzed by univariate analyses of variance comparing two groups at a time in order to locate the exact sources of variance between the groups. Discriminant scores obtained are used for visual representation and post-hoc predictive classifications. 105
(i) The results of the first multivariate analysis of variance comparing the three diagnostic groups: autistic, deaf-blind children and mentally retarded for any differences in the scores on five scales of the BRIAAC are tabulated in table 19. The obtained overall F statistic is 16.018 indicating highly significant differences at P= .000 between autistic, deaf-blind and mentally retarded groups, with a corresponding Wilk's Lambda = .278. Significant differences were obtained on all scales at P <.01 except for drive mastery which is insignificant at P = >.01. Therefore the null hypothesis that there are no significant differences in the three groups on the four BRIAAC scales is rejected. There are significant differences in the autistic, deaf-blind and mentally retarded children in terms of overall degree of disturbance and on relationship, communication, vocalization, psychobiological scales of the BRIAAC. However, on the drive mastery scale, the null hypothesis is accepted as there are no significant differences between the groups. Follow-up univariate analyses of variance are thus necessary. 106 A representation of the discriminant analysis in a two dimensional discriminant space is presented in Figure 2. The dependent variable cannonical coefficients have been used to produce the discriminant scores. The coefficients were standardized by the within-groups standard deviations so that their magnitude can be compared across variables with different scales. The scores produced by these coefficients have overall zero mean and unit standard deviation within groups. The discriminations obtained show clear delineation of mentally retarded from the autistic and deaf-blind groups. The latter two have considerable overlap.
The cannonical coefficients from the discriminant analysis were then used to produce a post-hoc analysis of actual group membership against predicted as shown in table 20. Based upon the five BRIAAC scales used, almost accurate classifications have been noted for the mentally retarded group, however the autistic and the deaf-blind groups have many characteristics in common to be misclassified in equal proportions. Deaf-blind children have no significant variability of scores common with mentally retarded children's classification. This 107 classification pattern indicates that the mentally retarded have distinct differences in variability patterns when compared with either of the two groups. But autistic children and deaf-blind, children though different in some aspects, can present patterns that are misclassified and support existing clinical observations of autistic like behaviors in some deaf- blind children.
TABLE 19
Multivariate analysis of variance/discriminant analysis Autistic, deaf-blind and mentally retarded children Total 115 children VARIABLE SS DF MS F P Relat 12481.527 2 6240.763 26.095 0.000 error 26785.569 112 239.157 Comm 6942.631 2 3471 13.316 0.000 error 29198.013 112 260.697 DrvMst 2670.150 2 1335.075 3.183 0.045 error 46978.424 112 419.450 Vocal 12557.460 2 6278.730 10.779 0.000 error 65421.671 112 582.515 Psybio 80696.153 2 40348.077 45.633 0.000 error 99028.608 112 884.184 Total 5 383782.066 2 191891.03 23.361 0.000 error 919983.099 112 8214.135 MULTIVARIATE TEST STATISTICS Wilk's Lambda= 0.278 F-Statistic=16.018 DF 12, 214 PROB= 0.00 Pillai Trace= 0.810 F-Statistic=12.252 DF 12, 216 PR0B= 0.00 Hotelling-Lawley Trace= 2.288 F-Statistic=20.209 DF 12, 212 PROB= 0.000 Theta= 0.682, S= 2, M 1.5, N= 52.5 PROB= 0.000 108
TABLE 20
Table of actual group membership against predicted Autistic, Deaf-blind and Mentally retarded groups
Table of groups (rows) by predict (Columns) Frequencies autistic deaf-blind retarded Total autistic 16 17 1 34 deaf-blind 14 30 2 46 retarded 1 1 33 35 Total 31 48 36 115 109
F fl C T 0 R < 2 )
FACTOR< 1)
FIGURE 2
Autistic, deaf-blind and mentally retarded groups represented in a two dimensional discriminant space A = Autism B = Deaf-Blind C = Mentally retarded 110 (ii) The second MANOVA was computed by expanding the deaf-blind groups into rubella deaf-blind and non- rubella deaf-blind groups. The results of this MANOVA comparing the scores of autistic, rubella deaf-blind, non rubella deaf-blind and mentally retarded group's scores on five scales of the BRIAAC are tabulated on table 21. The Overall F statistic obtained is 10.8 62 that indicates highly significant differences at P < .01, with a corresponding Wilk's Lambda = .242. Significant differences were obtained on all scales at P < 0.01, except for drive mastery, P = >.01. Therefore the null hypothesis that there are no sig nificant differences in the four groups on the five BRIAAC scales is rejected. There are significant dif ferences in the autistic, rubella deaf-blind, non- rubella deaf-blind and mentally retarded children in terms of overall degree of disturbance on relation ship, communication, vocalization, psychobiological scales of the BRIAAC. However, on the drive mastery scale, the null hypothesis is accepted and there are no significant differences between the groups in the degree of disturbance on this component. Follow-up univariate analysis of variance is thus necessary. Ill A representation of the discriminant analysis in a two dimensional space is presented in figure 3 with clear delineation of mentally retarded from the other three groups. The autistic, rubella and non rubella deaf-blind groups have considerable overlap.in some areas based upon scores of BRIAAC five scales.
A post-hoc analysis of actual group membership against predicted membership is presented in table 22. Here again, based upon the five BRIAAC scales, accurate predictions have been noted for mentally retarded group. However the autistic group has as many characteristics in common with the Rubella deaf-blind and non-rubella deaf-blind children. A third of the non-rubella deaf-blind and a fifth of rubella children have been predicted to be classified as autistic in their variability of scores. No non-rubella deaf-blind have been classified to belong to the rubella deaf- blind group. Incidentally, none of the Autistic, rubella deaf-blind and the non-rubella deaf blind have been classified as belonging to the mentally retarded group. This analysis presents a distinctness of pathology manifested by the mentally retarded group, but proportional differences in that of the other three groups. 112 TABLE 21
Multivariate analysis of variance/discriminant analysis Autistic, rubella deaf-blind, non-rubella deaf-blind and mentally retarded children: Total 115 children VARIABLE SS DF MS F P Relat 12494.56 3 4164.853 17.268 0.000 error 26772.536 111 241.194 Comm 6942.695 3 2314.232 8.798 0.000 error 29197.949 111 263.045 DrvMst 2672.666 3 890.889 2.105 0.104 error 46975.908 111 423.206 Vocal 14616.202 3 4872.067 8.559 0.000 error 63182.928 111 569.216 Psybio 80709.285 3 26903.095 30.159 0.000 error 99015.475 111 892.031 Total 5 392546.48 3 130848.82 15.939 0.000 error 911218.68 111 8209.177
MULTIVARIATE TEST STATISTICS
Wilk's Lambda= 0.242 F-Statistic=10.862 DF= 18, 300 PROB= 0.00
Pillai Trace= 0.927 F-Statistic=8.054 DF= 18, 324 PROB= 0.00
Hotelling-Lawley Trace= 2.457 F-Statistic=14.285 DF= 18, 314 PROB= 0.000
Theta= 0.684, S= 3, M= 1.0, N= 52. PROB= 0.000 113 TABLE 22
Table of actual group membership against predicted Autistic, rubella, non-rubella and mentally retarded groups Table of groups (rows) by predict (Columns) Frequencies rubella mentally non-rubel autistic deafblind retarded deafblind Total autistic 15 11 0 8 34 rubella 5 20 0 6 31- retarded 1 1 33 0 35 nonrubella 3 2 0 10 15 Total 24 34 33 24 115
F fl C T 0 R < 2 >
FIGURE 3
Autistic, rubella deaf-blind, non-rubella deaf-blind and mentally retarded groups represented in a two dimensional discriminant space A = Autism B = Rubella Deaf-Blind C = Mentally retarded D = Non-rubella deaf-blind 114 (iii) The third MANOVA was computed to compare the scores of autistic, rubella Deaf-blind and non-rubella deaf-blind children on all eight scales of the BRIAAC. The distinction between the two groups of deaf-blind children represents distinct etiologies and should reveal underlying differences and similarities in comparison to autistic children. The results are indicated on table 23. The overall F statistic obtained is 5.619 that indicates highly significant differences between the groups at P <.01, with a corresponding Wilk's Lambda = 0.333. Therefore, the null hypothesis that there are no significant differences in the three groups on the eight BRIAAC scales is rejected. There are significant differences in the degree of disturbance between the three groups. Significant differences have been noted on only four of the eight scales: vocalization, sound and speech, social responsiveness and body movement. No significant differences have been obtained on relationship, communication, drive mastery and psychobiological P = > 0.01. The total cumulative score is significantly different at only P = <0.017 Follow-up univariate analysis of variance is thus necessary. 115 A representation of the discriminant analysis of the three groups in a two dimensional space based upon cannonical correlation coefficients is presented in figure 4 with clear delineation of autistic group from the Rubella and non rubella deaf-blind groups. The latter two indicate some overlap.
A post-hoc analysis of actual group membership against predicted membership based upon the scores of the discriminant analysis is presented in table 24. Based upon the eight BRIAAC scales, no non-rubella deaf-blind were misclassified as autistic but an eighth of the autistic, and a fifth of rubella deaf blind were misclassified among each other on the basis of predicted scores indicating overlap in some behaviors. 116
TABLE 23
Multivariate analysis of variance/discriminant analysis Autistic, rubella deaf-blind and non-rubella deaf-blind children: Total 80 children VARIABLE SS DF MS F P Relat 127.352 2 63.67 0.255 0.776 error 19236.53 72 249.82 Comm 1056.68 2 528.34 1.986 0.144 error 20483.20 72 266.01 DrvMst 128.864 2 64.43 0.199 0.820 error 24918.93 72 323.62 Vocal 5076.045 2 2538.02 6.328 0.003 error 30884.64 72 401.099 Snd Speech 20322.97 2 10161.488 25.519 0.000 error 30660.91 72 398.194 Soc. Respon 3412.87 2 1706.43 7.188 0.001 error 18278.61 72 237.38 Body Mvt 5036.466 2 2518.233 8.194 0.001 error 23663.72 72 307.321 Psybio 119.260 2 59.630 0.343 0.711 error 13392.79 72 173.932 Total 113193.59 2 56596.79 4.281 0.017 error 1018080.6 72 13221.82
MULTIVARIATE TEST STATISTICS Wilk's Lambda= 0.333 F-Statistic=5.619 DF= 18, 138 PROB= 0.00
Pillai Trace= 0.801 F-Statistic=5.201 DF= 18, 140 PROB= 0.00
Hotelling-Lawley Trace= 1.599 F-Statistic=6.042 DF= 18, 136 PROB= 0.000 Theta=0.562- S= 2, M= 3.0, N= 33.5 PROB= 0.000 117
TABLE 24
Table of actual group membership against predicted Autistic, rubella deaf-blind and non-deaf-blind
Table of groups (rows) by predict (Columns) Frequencies rubella non-rubella autistic deaf-blind deaf-blind Total autistic 27 4 3 34 rubella 4 21 6 31 deaf-blind non-rubella 0 3 12 15 deaf-blind Total 31 28 21 80 118
3 , , , —1 B B F 2 BU B fl fl fl fi C RB B fla T 1 0 BBBB^fl^ fl „ fl R < 0 - 2 > -1 B • c 8 A fl -2 cc^-c c c fl -3 . c . 1 -4 -2
FACTOR< 1 >
FIGURE 4
Autistic, rubella deaf-blind and non-rubella deaf-blind groups represented in a two dimensional discriminant space A = Autism B = Rubella Deaf-Blind C = Non-rubella deaf-blind 119
The second hypothesis asked whether there is any evidence that the component behaviors comprising BRIAAC are equally affected in the low functioning deaf-blind and autistic children or is there a difference in the patterning of these components? In the later case, what is the nature of the different pattern. The null hypothesis proposed was that there are no significant differences in the component behaviors comprising the BRIAAC in the low functioning deaf-blind and autistic children. In order to test this hypothesis, several bivariate analyses of variance were performed to compare and point to the sources of variance between the groups so that patterns of BRIAAC components may be found. Analyses of variance comparisons between the autistic and the deaf-blind groups for differences in patterns and with the control group of mentally retarded children to account for comparative patterns of mental retardation in the low functioning deaf-blind groups were done. In addition to testing the hypothesis 2, these comparisons will add support to hypothesis 1 by narrowing down comparisons to between two groups at a time. 120
The following sequence of ANOVAs have been considered. a) autistic X deaf-blind b) autistic X rubella deaf-blind c) autistic X non-rubella deaf-blind d) rubella deaf-blind X non-rubella deaf blind e) mentally retarded X autistic f) mentally retarded X deaf-blind g) mentally retarded X rubella deaf-blind h) mentally retarded X non-rubella deaf blind
(i) Analysis of variance comparing autistic and deaf-blind groups (refer to table 25) : In addition to comparing the degree of disturbance in the pathology of the two groups this ANOVA essentially compares the performance of the groups on the component behaviors comprising BRIAAC. With an overall F statistic of 9.792, and a Wilk's Lambda of 0.443, P <0.01, the null hypothesis that there are no significant differences in the patterning of the components of the BRIAAC in the autistic and deaf-blind groups is rejected. Significant differences were obtained on vocalization, 121 sound and speech, social responsiveness, and body movement and the total cumulative score all of which are significant at P=<0.01. However, no significant differences exist on relationship, communication, drive mastery, and psychobiological scales where p = >0.01
A post hoc analysis of actual group membership against predicted based upon cannonical correlation coefficients is represented in table 26, In this classification comparison, the autistic and the deaf blind groups seem to present different clusters of patterns in their pathology.
(ii) Analysis of variance comparing autistic and rubella deaf-blind groups (see table 27) : The overall F statistic of 9.408, and a Wilk's Lambda of 0.394, P <0.01. indicates that the autistic and the rubella deaf-blind are significantly different in the overall degree of disturbance, and thus the null hypothesis that there are no significant differences in their overall degree of disturbance is rejected. Univariate comparisons show significant differences on vocalization, sound and speech, social responsiveness, and body movement and the total cumulative scores. 122
TABLE 25
Multivariate analysis of variance/discriminant analysis Autistic and deaf-blind children: Total 80 children VARIABLE SS DF MS F P Relat 114.318 1 114.318 0.463 0.498 error 19249.56 78 246.78 Comm 1056.618 1 1056.61 4.024 0.048 error 20483.27 78 262.60 DrvMst 126.347 1 126.34 0.395 0.531 error 24921.45 78 319.50 Vocal 3017.30 1 3017.30 7.144 0.009 error 32943.38 78 422.35 Snd Speech 16414.01 1 16414.012 37.035 0.000 error 34569.87 78 443.204 Soc. Respon 3380.43 1 3380.43 14.40 0.000 error 18311.05 78 234.75 Body Mvt 4840.57 1 4840.57 15.824 0.000 error 23859.61 78 305.89 Psybio 106.128 1 106.12 0.617 0.434 error 13405.92 78 171.87 Total 105366.07 1 105366.07 8.011 0.006 error 1025908.1 78 13152.66
MULTIVARIATE TEST STATISTICS
Wilk's Lambda=0.443 F-Statistic=9.792 DF= 9, 70 PR0B= 0.00
Pillai Trace=0.557 F-Statistic=9.792 DF= 9, 70 PR0B= 0.00
Hotelling-Lawley Trace= 1.259 F-Statistic=9.792 DF= 9, 70 PROB= 0.000 123
TABLE 26
Table of actual group membership against predicted Autistic and deaf-blind groups Table of groups (rows) by predict (Columns) Frequencies autistic deaf-blind Total autistic 29 5 34 deaf-blind 6 40 46 Total 35 45 80
In all of these components the value of p is less than 0.01., thus indicating differences in their patterning of BRIAAC responses. However no significant differences exist on relationship, communication, drive for mastery,and psychobiological scales, on all of which p > 0.01.
A post hoc analysis of actual group membership against predicted based upon discriminations generated by cannonical correlation coefficients are presented in table 28, where autistic and rubella deaf-blind are indicated to be distinct groups with a misclassification of four cases in each group pointing to possible some overlap of the variability of scores. 124 TABLE 27
Multivariate analysis of variance/discriminant analysis Autistic and rubella deaf-blind children: Total 65 children VARIABLE SS DF MS F P Relat 126.08 1 126.08 0.456 0.502 error 17400.136 63 276.19 Comm 882.589 1 882.58 2.987 0.089 error 18617.47 63 295.51 DrvMst 91.812 1 91.81 0.262 0.611 error 22093.20 63 350.68 Vocal 4728.71 1 4728.711 10.952 0.002 error 27201.04 63 431.76 Snd Speech 20306.74 1 20306.74 52.38 0.000 error 24421.31 63 387.64 Soc. Respon 2560.26 1 2560.26 9.944 0.002 error 16220.877 63 257.47 Body Mvt 3315.79 1 3315.79 10.484 0.002 error 19925.98 63 316.28 Psybio 62.18 1 62.18 0.369 0.546 error 10628.95 63 168.714 Total 110332.96 1 110332.96 7.668 0.007 error 906466.89 63 14388.36
MULTIVARIATE TEST STATISTICS Wilk's Lambda=0.394 F-Statistic=9.408 DF= 9, 55 PROB= 0.00
Pillai Trace=0.606 F-Statistic=9.408 DF= 9, 55 PROB= 0.00
Hotelling-Lawley Trace=1.54 F-Statistic=9.408 DF= 9, 55 PROB= 0.000 125 TABLE 28
Table of actual group membership against predicted Autistic and Rubella group
Table of groups (rows) by predict (Columns) Frequencies rubella autistic deaf-blind Total autistic 30 4 34 rubella 4 27 31 deaf-blind Total 34 31 65
(iii) Analysis of variance comparing autistic and non- rubella deaf blind groups (refer to table 29) In addition to comparing the overall degree of disturbance in the pathology of the two groups, this ANOVA compares the performance of the groups on the component behaviors comprising the BRIAAC. The results indicate overall differences in the degree of disturbance with an overall F statistic of 4.534, and a Wilk's Lambda of 0.489, p <0.01. Thus the null hypothesis that there are no significant differences between the degree of disturbance between the autistic and non-rubella deaf-blind is rejected. There are some different BRIAAC component patterns in the pathologies 126 that lead these two groups to be different. Univariate comparisons between the groups on each of the BRIAAC scales show significant differences on only two scales: social responsiveness and body movement where the value of P = <0.01. There were no significant differences on relationship, communication, drive mastery, sound and speech, vocalization, and psychobiological scales, and the cumulative total score in all of which P = >0.01. Thus the two groups have very few differences in the variability of their scores. Yet the hypothesis that there are indeed differences in the patterning of the components of the BRIAAC holds true. This argument is further supported in the post hoc analysis of actual group membership against predicted based upon cannonical correlation coefficients where almost none of the BRIAAC scores for the non-rubella deaf-blind are misclassified as autistic (see table 30). However, almost a fifth of the autistic children's scores based upon their variability can lead to their being grouped as similar to the non-rubella deaf-blind. 127 TABLE 29
Multivariate analysis of variance/discrimination analysis . Autistic and non-rubella deaf-blind children Total 49 children VARIABLE SS DF MS F P Relat 28.437 1 28.437 0.099 0.755 error 13558.665 47 288.48 Comm 554.353 1 554.353 1.693 0.200 error 15387.85 47 327.401 DrvMst 86.235 1 86.235 0.204 0.654 error 19861.96 47 422.595 Vocal 81.943 1 81.943 0.131 0.719 error 29355.15 47 624.578 Snd Speech 2573.204 1 2573.204 5.666 0.021 error 21345.04 47 454.150 Soc. Respon 2145.325 1 2145.325 7.506 0.009 error 13432.67 47 285.802 Body Mvt 3640.39 1 3640.394 9.659 0.003 error 17713.85 47 376.890 Psybio 99.896 1 99.89 0.522 0.474 error 8996.451 47 191.414 Total 31097.52 1 31097.52 1.732 0.195 error 844035.29 47 17958.19
MULTIVARIATE TEST STATISTICS Wilk's Lambda= 0.489 F-Statistic=4.534 DF= 9, 39 PROB= 0.00
Pillai Trace= 0.511 F-Statistic=4.534 DF= 9, 39 PROB= 0.00
Hotelling-Lawley Trace=l.046 F-Statistic=4.534 DF= 9, 39 PROB= 0.000 128
TABLE 30
Table of actual group membership against predicted Autistic and non-rubella deaf-blind
Table of groups (rows) by predict (Columns) Frequencies non-rubella autistic deaf-blind Total autistic 28 6 34 non-rubella 1 14 15 deaf-blind Total 29 20 49
(iv) Analysis of variance comparing rubella deaf-blind and Non-rubella deaf-blind groups (refer to table 1): This analysis of variance was computed to compare the rubella and non-rubella deaf-blind groups to see if there is any difference in the degree of disturbance between these two deaf-blind groups which have diverse etiologies. The overall F statistic of 2.456, and a Wilk's Lambda of 0.620, are significant only at P=0.02. Therefore the null hypothesis is accepted that there are no differences in the overall degree of disturbance between the deaf-blind groups; p >0.01. Yet looking at the univariate analysis 129 comparing each of the BRIAAC scales, two scales: vocalization, (P= <0.001), and sound and speech, (P=<0.008) have significant differences in the patterning of the components of the BRIAAC. No significant differences exist on relationship, communication, drive mastery, social responsiveness, body movement, psychobiological, the cumulative total scores. No additional discriminant analysis were necessary because of the overall insignificant differences at P >0.01 between the rubella deaf-blind and the non-rubella deaf-blind but a table of actual group membership against predicted is presented and significant only p = 0.02. (see table 32.)
Analyses of variances individually comparing all the groups with the control group of mentally retarded children for mental retardation are presented in the sequences below. Scores of only five scales of the BRIAAC were available for the mentally retarded children and so all comparisons in this sequence compare these five scales with the other groups instead the full protocol of eight scales. A sub total of five scales is also included for comparisons: 130
TABLE 31
Multivariate analysis of variance/discriminant analysis Rubella deaf-blind and non-rubella deaf-blind children Total 46 children VARIABLE SS DF MS F P Relat 32.947 1 32.947 0.193 0.662 error 7494.357 44 170.32 Comm 6.933 1 6.933 0.044 0.835 error 6954.219 44 158.050 DrvMst 1.789 1 1.789 0.010 0.921 error 7883.42 44 179.169 Vocal 1579.89 1 1579.893 12.213 0.001 error 5691.93 44 129.36 Snd Speech 2902.50 1 2902.50 7.711 0.008 error 16561.93 44 376.408 Soc. Respon 24.46 1 24.461 0.156 0.695 error 6911.64 44 157.083 Body Mvt 92.411 1 92.411 0.415 0.523 error 9791.08 44 222.525 Psybio 17.58 1 17.586 0.108 0.744 error 7155.71 44 162.63 Total 7057.628 1 7057.628 1.084 0.303 error 286428.96 44 6509.74
MULTIVARIATE TEST STATISTICS Wilk's Lambda= 0.620 F-Statistic= 2.456 DF= 9, 39 PROB= 0.02
Pillai Trace= 0.380 F-Statistic= 2.456 DF= 9, 39 PROB= 0.02
Hotelling-Lawley Trace= 0.614 F-Statistic= 2.456 DF= 9, 39 PROB= 0.02 131
TABLE 32
Table of actual group membership against predict Rubella deaf-blind and non-rubella deaf-blind
Table of groups (rows) by predict (Columns) Frequencies rubella non-rubella deaf-blind deaf-blind Total rubella 11 3 14 deaf-blind non-rubella 7 25 32 deaf-blind Total 18 28 46
(v) Analysis of variance comparing autistic and mentally retarded groups (refer to table 33): In terms of the overall degree of disturbance as measured by the BRIAAC, the autistic and mentally retarded groups are significantly different. With an overall F statistic of 23.994, and a Wilk's Lambda of 0.0.301, P <0.01, the null hypothesis that there are no overall significant differences is rejected. In the patterning of the components of the BRIAAC, significant differences have been noted on relationship,, psychobiological, and the cumulative sub-total score of the 5 scales, p < 0.01. No 132 significant differences exist on communication, drive for mastery, and vocalization, where p = >0.01. A follow-up post hoc discriminant analysis based upon cannonical correlation coefficients of actual group membership against predicted is represented in table 34, showing no misclassification of the autistic group with the mentally retarded group. The two groups are very distinct in terms of their variability and patterning on the BRIAAC.
TABLE 33
Multivariate analysis of variance/discriminant analysis Autistic and mentally retarded children Total 69 children VARIABLE SS DF MS F P Relat 7712.54 1 7712.54 26.832 0.000 error 19258.26 67 287.43 Comm 2210.38 1 2210.386 6.66 0.012 error 22236.86 67 331.89 DrvMst 1323.34 1 1323.34 2.268 0.137 error 39093.20 67 583.48 Vocal 2760.35 1 2760.35 3.190 0.079 error 57969.84 67 865.22 Psybio 54456.98 1 54456.98 39.721 0.000 error 91855.30 67 1370.97 Total 5 203992.14 1 203992.14 17.388 0.000 error 786023.18 67 11731.68 MULTIVARIATE TEST STATISTICS Wilk's Lambda=0.301 F-Statistic=23.994 DF= 6, 62 PROB= 0.00 133
TABLE 34
Table of actual group membership against predicted Autistic and mentally retarded groups
Table of groups (rows) by predict (Columns) Frequencies autistic mentally Total retarded autistic 34 0 34 mentally 3 32 35 retarded Total 37 32 69
(vi) Analysis of variance comparing mentally retarded and deaf-blind group (refer to table 35): This analysis of variance compares the scores of the mentally retarded group with that of deaf-blind group to see if there are any differences in the overall degree of disturbance between the two groups and thereby controlling for mental retardation in the deaf-blind if differences are observed. The overall F statistic is 29.757 and a Wilk's Lambda is 0.293, at P < 0.01. Therefore, the mentally retarded group and the deaf-blind group are significantly different in their overall degree of disturbance based upon the 134 five BRIAAC scales. The null hypothesis that there are no significant differences in the pathology of mental retardation and low-functioning deaf-blind is rejected. Significant differences have been noted on all five scales and the total of the five scales,at p=<0.01. Thus there are significant differences in the patterning of the components of the BRIAAC between the mentally retarded group and the deaf-blind group..
A post hoc analysis of actual group membership against predicted based upon discriminant scores using cannonical correlation coefficients is presented in table 36, Where the BRIAAC responses of the mentally retarded and deaf-blind group have almost nothing in common in terms of their variability of scores. Only one case in 46 of the deaf-blind and one case of the 35 mentally retarded have been misclassified based upon predicted performance. Thus, based upon their BRIAAC performances, the effects of low-functioning in the deaf-blind are not the same as mental retardation in the mentally retarded group, or more liberally put, low functioning deaf-blind children are not essentially mentally retarded. 135
TABLE 35
Multivariate analysis of variance/discriminant analysis Deaf-blind and mentally retarded children Total 81 children
VARIABLE SS DF MS F P Relat 11037.83 1 11037.83 57.88 0.000 error 15063.30 79 190.67 Comm 6930.32 1 6930.32 34.926 0.000 error 15675.89 79 198.42 DrvMst 2538.87 1 2538.87 6.699 0.011 error 29942.189 79 379.01 Vocal 12497.024 1 12497.02 24.95 0.000 error 39570.112 79 500.887 Psybio 68074.51 1 68074.51 57.95 0.000 error 92795.99 79 1174.633 Total 5 358506.38 1 358506.38 43.98 0.000 error 643904.5 79 8150.69
MULTIVARIATE TEST STATISTICS
Wilk's Lambda=0.293 F-Statistic=29.757 DF= 6, 74 PR0B= 0.00
Pillai Trace=0.707 F-Statistic=29.757 DF= 6, 74 PROB= 0.00
Hotelling-Lawley Trace=2.413 F-Statistic=29.757 DF= 6, 74 PROB= 0.000 136 TABLE 36
Table of actual group membership against predicted Deaf-blind and mentally retarded Table of groups (rows) by predict (Columns) Frequencies mentally deaf-blind retarded Total deaf-blind 45 1 46 mentally 1 34 35 retarded Total 46 35 81
The deaf-blind group was further compared with the mentally retarded group by splitting into the rubella and the non-rubella groups so that any effects similar to those of mental retardation may become obvious. Thus the following two analyses of variance have been computed.
(vii) Analysis of variance comparing mentally retarded and rubella deaf-blind groups (see table 37): In terms of overall degree of disturbance on five scales as measured by the BRIAAC, the mentally retarded and the rubella deaf-blind groups are significantly different. With an overall F statistic of 26.609, and a Wilk's Lambda of 0.273, P < 0.01, the null hypothesis that there are no overall significant 137 differences in the pathology of mental retardation and low functioning rubella deaf-blind in terms of BRIAAC performance is rejected. In the patterning of the components of the BRIAAC, significant differences have been noted in relationship, communication, vocalization, and psychobiological scales and the sub total of 5 scales in all of which P = <0.01. However, there are no significant differences on the drive mastery scale where p = >0.01. No further analyses have been done since the purpose of this comparison was to compare the scores for control of mental retardation, and again, the effects of low functioning are not the same as mental retardation.
(viii) Analysis of variance comparing mentally retarded and non-rubella deaf-blind groups (see table 38) : This analysis of variance compares the scores of the mentally retarded group with those of the non- rubella deaf-blind to see if there are any overall differences in the degree of disturbance between the two groups and, thereby indicating possible effects of mental retardation in the low functioning non-rubella deaf-blind. The overall F statistic of 26.609, and a Wilk's Lambda of 0.727, at P < 0.01. Therefore, the 138 TABLE 37
Multivariate analysis of variance/discriminant analysis Rubella deaf-blind and mentally retarded children
VARIABLE SS DF MS F P Relat 9729.216 1 9729.216 47.73 0.00 error 13249.50 65 203.83 Comm 5989.90 1 5989.904 28.085 0.00 error 13862.96 65 213.276 DrvMst 2086.223 1 2086.223 5.001 0.029 error 27114.97 65 417.153 Vocal 14010.93 1 14010.936 26.453 0.000 error 34427.00 65 529.646 Psybio 56454.125 1 56454.125 40.763 0.000 error 90020.404 65 1384.929 Total 5 343963.12 1 343963.12 39.289 0.000 error 569061.56 65 8754.79
MULTIVARIATE TEST STATISTICS Wilk's Lambda= 0.273 F-Statistic= 26.609 DF= 6, 60 PROB= 0.00
mentally retarded group and the non-rubella deaf-blind groups are significantly different in the overall degree of disturbance based upon the five BRIAAC scales. The null hypothesis that there are no significant differences in the pathology of mental retardation and low-functioning non-rubella deaf-blind is rejected. Significant differences have been noted in relationship, communication, psychobiological and the sub-total of the 5 scales; with P = <0.01 on all 139 of them. However, no significant differences have been noted in drive mastery and in vocalization where P = > 0.01. Thus, there are significant differences in the patterning of the components of the BRIAAC between the mentally retarded group and the low functioning non-rubella deaf-blind group.
TABLE 38
Multivariate analysis of variance/discriminant analysis Non-rubella deaf-blind and mentally retarded children Number of children 49 VARIABLE SS DF MS F P Relat 4966.531 1 4966.53 25.054 0.000 error 9316.85 47 198.231 Comm 3270.93 1 3270.93 14.612 0.000 error 10520.74 47 223.84 DrvMst 1345.60 1 1345.6 2.542 0.118 error 24882.4 47 529.41 Vocal 2629.031 1 2629.031 3.446 0.070 error 35861.5 47 763.01 Psybio 35351.51 1 35351.51 18.8 0.000 error 88380.68 47 1880.44 Total 5 128595.6 1 128595.6 10.493 0.002 error 575996.4 47 12255.24
MULTIVARIATE TEST STATISTICS
Wilk's Lambda=0.346 F-Statistic=13.235 DF= 6, 42 PROB= 0.00 140 A composite view of the significant differences in the components of the BRIAAC across all the diagnostic groups compared with the analyses of variances have been presented in tables 39 through 41 for easy comparison.
TABLE 39
F-values when compared with the autistic groups Scales Deaf-Blind Rubella Nonrubella Mentally as a group Deaf-Blind Deaf-blind Retarded Relationship 0.463 0.456 0.099 26.83
Communication 4.024 2.987 1.693 6.66
Drive Mastery 0.395 .262 0.024 2.268
Vocalization 7.144 10.952 0.131 3.19
Sound/Speech 37.035 52.386 5.666
Social 14.4 9.944 7.506 Responsiveness Body Movement 15.82 10.484 9.659
Psychobiological .617 .369 0.522 39.721
Total 8.011 7.668 1.732 17.388 5 SCALES BOLD LETTERS INDICATE SIGNIFICANT DIFFERENCES AT P=<0.01 141
Table 40
F-values when compared with mentally retarded group Scales Rubella NonRubella Deaf-Blind Deaf-Blind Deaf-blind as a group Relationship 47.73 25.054 57.88 Communication 28.08 14.612 34.92 Drive Mastery 5.001 2.542 6.699 Vocalization 26.45 3.446 24.95 Psychobiological 40.76 18.8 57.95 Total 5 SCALES 39.28 10.493 43.98 BOLD LETTERS INDICATE SIGNIFICANT DIFFERENCES AT P=<0.01
TABLE 41
F-values when compared with rubella deaf-blind children Scales NonRubella Deaf-Blind Relationship 0.193 Communication 0.044 Drive Mastery 0.010 Vocalization 12.213 Sound/Speech 7.711 Social 0.156 Responsiveness Body Movement 0.415 Psychobiological 0.108 Total 1.084 BOLD LETTERS INDICATE SIGNIFICANT DIFFERENCES AT P=<0.01 142 (5) Follow-up analyses in the form of post hoc multiple comparisons based upon Tukey's (HSD) test comparing the BRIAAC scores of autistic, rubella deaf blind, non-rubella deaf-blind and mentally retarded children are presented below. The Tukey's (HSD) procedure has been set for alpha = .01 and assumes that the counts per group are equal. Bartlett's test of homogeneity of group variables are also presented in tables 42 through 49.
Based upon these multiple comparisons, the differences between the diagnostic groups on each scale are the same as have been determined by the many analyses of variances presented so far. The results for each scale are as follows: Relationship scale: The critical range for pairs of means is 13.059. Only the mentally retarded group's mean differs significantly from all other groups' means (p <.01). No significant differences exist in the means of the autistic, rubella deaf-blind, and non-rubella deaf-blind groups on the relationship scale. Communication scale: The critical range for pairs of means is 13.638. Only the mean of the mentally retarded group differs significantly from all 143 other groups' means (p <.01). No significant differences exist in the means of the autistic, rubella deaf-blind, and non-rubella deaf-blind groups on the communication scale. Drive for mastery scale: The critical range for pairs of means is 17.299. No significant differences exist in the means of any groups. Vocalization scale: The critical range for pairs of means is 20.0 62. The means of the mentally retarded and the rubella deaf-blind groups differ significantly from each other (p <.01). No significant differences exist in the means of the autistic, rubella deaf-blind and non-rubella deaf-blind groups. Sound and speech reception scale: The critical range for pairs of means is 16.178. Significant differences exist in the means of the autistic, the rubella deaf-blind, and the non-rubella deaf-blind groups (p <.01). Social responsiveness scale: The critical range for pairs of means is 12.676. The mean of the autistic group is significantly different from that of the rubella deaf-blind and the non-rubella deaf-blind groups (p <.01). There are no differences in the means of rubella deaf-blind and non-rubella deaf-blind groups. 144 Body movement scale: The critical range for pairs of means is 14.457. The mean of the autistic group is significantly different from the means of the rubella deaf-blind and the non-rubella deaf-blind groups (p=0.001). There are no differences in the means of the rubella deaf-blind and the non-rubella deaf-blind groups. Psychobiological scale: The critical range for pairs of means is 25.115. Only the mean of the mentally retarded group differs significantly from all other groups' means (p <.01). No significant differences exist in the means of the autistic, the rubella deaf-blind, and the non-rubella deaf-blind groups on this scale. 145
Table:42
Multiple comparison Relationship scale: autistic, rubella deaf-blind, non-rubella deaf-blind and mentally retarded children
BARTLETT TEST FOR HOMOGENEITY OF GROUP VARIANCES CHI-SQUARE = 5.799 DF= 3 PROBABILITY = .122
ANALYSIS OF VARIANCE SOURCE SUM OF SQUARES DF MEAN SQUARE F PROBABILITY BETWEEN GROUPS 12494.56 3 4164.85 17.268 .000 WITHIN GROUPS 26772.53 111 241.194
TUKEY HSD TEST AT ALPHA = .010 CRITICAL RANGE FOR PAIRS OF MEANS = 13.059
Table:43
Multiple comparison Communication scale: autistic, rubella deaf-blind, non-rubella deaf-blind and mentally retarded children BARTLETT TEST FOR HOMOGENEITY OF GROUP VARIANCES CHI-SQUARE = 8.745 DF= 3 PROBABILITY = .033
ANALYSIS OF VARIANCE SOURCE SUM OF SQUARES DF MEAN SQUARE F PROBABILITY BETWEEN GROUPS 6942.695 3 2314.232 8.798 .000 WITHIN GROUPS 29197.949 111 263.045
TUKEY HSD TEST AT ALPHA = .010 CRITICAL RANGE FOR PAIRS OF MEANS = 13.638 146
Table:44
Multiple comparison Drive Mastery scale: autistic, rubella deaf-blind, non-rubella deaf-blind and mentally retarded children BARTLETT TEST FOR HOMOGENEITY OF GROUP VARIANCES CHI-SQUARE = 16.613 DF= 3 PROBABILITY = .001
ANALYSIS OF VARIANCE SOURCE SUM OF SQUARES DF MEAN SQUARE F PROBABILITY BETWEEN GROUPS 2672.666 3 890.889 2.105 .104 WITHIN GROUPS 46975.908 111 423.206
TUKEY HSD TEST AT ALPHA = .010 CRITICAL RANGE FOR PAIRS OF MEANS = 14.805
Table:45
Multiple comparison Vocalization scale: autistic, rubella deaf-blind, non-rubella deaf-blind and mentally retarded children BARTLETT TEST FOR HOMOGENEITY OF GROUP VARIANCES CHI-SQUARE = 54.523 DF= 3 PROBABILITY = 0.000
ANALYSIS OF VARIANCE SOURCE SUM OF SQUARES DF MEAN SQUARE F PROBABILITY BETWEEN GROUPS 14616.202 3 4872.06 8.559 .000 WITHIN GROUPS 63182.988 111 569.216
TUKEY HSD TEST AT ALPHA = .010 CRITICAL RANGE FOR PAIRS OF MEANS = 20.062 147
Table:46
Multiple comparison Sound and speech reception: autistic and deaf-blind groups
BARTLETT TEST FOR HOMOGENEITY OF GROUP VARIANCES CHI-SQUARE = 1.066 DF= 2 PROBABILITY = .587
ANALYSIS OF VARIANCE SOURCE SUM OF SQUARES DF MEAN SQUARE F PROBABILITY BETWEEN GROUPS 21236.094 2 10618.047 27.484 0.000 WITHIN GROUPS 29747.794 77 386.335
TUKEY HSD TEST AT ALPHA = .010 CRITICAL RANGE FOR PAIRS OF MEANS = 16.178
Table:47
Multiple comparison Social responsiveness scale: autistic and deaf-blind groups
BARTLETT TEST FOR HOMOGENEITY OF GROUP VARIANCES CHI-SQUARE = 5.826 DF= 2 PROBABILITY = .054
ANALYSIS OF VARIANCE SOURCE SUM OF SQUARES DF MEAN SQUARE F PROBABILITY BETWEEN GROUPS 3428.791 2 1714.396 7.228 .001 WITHIN GROUPS 18262.696 77 237.178
TUKEY HSD TEST AT ALPHA = .010 CRITICAL RANGE FOR PAIRS OF MEANS = 12.676 148
Table:48
Multiple comparison Body Movement Scale: autistic and deaf-blind groups
BARTLETT TEST FOR HOMOGENEITY OF GROUP VARIANCES CHI-SQUARE = 4.104 DF= 2 PROBABILITY = .128
ANALYSIS OF VARIANCE SOURCE SUM OF SQUARES DF MEAN SQUARE F PROBABILITY BETWEEN GROUPS 4945.059 2 2472.530 8.014 .001 WITHIN GROUPS 23755.128 77 308.508
TUKEY HSD TEST AT ALPHA = .010 CRITICAL RANGE FOR PAIRS OF MEANS = 14.457
Table:49
Multiple comparison Psychobiological Scale: autistic, rubella deaf-blind, non-rubella deaf-blind and mentally retarded children BARTLETT TEST FOR HOMOGENEITY OF GROUP VARIANCES CHI-SQUARE = 89.695 DF= 3 PROBABILITY = .000
ANALYSIS OF VARIANCE SOURCE SUM OF SQUARES DF MEAN SQUARE F PROBABILITY BETWEEN GROUPS 80709.285 3 26903.095 30.159 .000 WITHIN GROUPS 99015.475 111 892.031
TUKEY HSD TEST AT ALPHA = .010 CRITICAL RANGE FOR PAIRS OF MEANS = 25.115 149
Table 50
Tukey's multiplecomparison test: table of critical mean ranges for BRIAAC scales and mean scores of diagnostic groups Scale Non- Critical Rubella rubella Mentally range for mean Autistic deaf-blind deaf-blind retarded Relationship 44.853 42.065 43.200 66.000 13.059 Communication 41.765 34.387 34.467 53.086 13.638 Drive mastery 41.412 39.032 38.533 50.171 17.229 Vocalization 37.206 20.129 34.400 49.857 20.062 Sound and speech 60.324 24.935 44.600 16.176 social response. 52.824 40.258 38.460 12.676 Body movement 55.235 40.935 36.530 14.457 Psychobiological 41.265 39.306 38.167 97.457 25.115 Total 5 scales 206.500 171.355 200.800 315.257
Cumulative total 364.794 282.306 310.130 94.653 150 (6) One other way to compare the performance of the components of the BRIAAC across the diagnostic groups, is by considering the consistency of scores by comparing intercorrelations among the components of BRIAAC for each group. Pearson correlation matrix for each group on the BRIAAC are presented on tables 50 through 54. In the autistic group, the scores on all measures are highly positively correlated with the intercorrelations between .93 and .47. Drive for mastery and body movement seem to have the lowest but moderately positive correlations. In the rubella children's' correlation matrix there is a greater variability in the intercorrelations, with the highest correlation at .88 and the lowest .04. Lowest correlations are seen in vocalization and sound and speech reception. In the non-rubella deaf-blind group, intercorrelations range from 0.90 to -0.22. Speech and sound reception is negatively correlated with almost all scales. Intercorrelations for the retarded group range from 0.97 to 0.04. Very low correlations were obtained between relationship and the other scales as opposed to the other groups. Extreme variations in the intercorrelations have been interpreted as the degree of compartmentalization among the pathological groups. Thus, in sharp contrast to the autistic group, the rubella children are more compartmentalized with frequent low correlations. The non- 151 rubella deaf-blind fall in the middle of these two groups. The mentally retarded have low correlations between scales that correlate highly in the other groups. Here again we see that there is a difference in the patterning of responses on the BRIAAC components in the groups considered.
TABLE 51
Pearson correlation matrix: autistic children Relat Comm DrvMst Vocal Snd Spech Relat 1.00 Comm .895 1.00 DrvMst .679 .713 1.00 Vocal .827 .772 .697 1.00 Snd Spech .755 .728 .754 .751 1.00 Soc Resp .916 .840 .632 .829 .780 Body Mvt .699 .663 .475 .715 .650 Psybio .618 .552 .568 .768 .606 Total .865 .866 .861 .831 .804 AGE .249 .149 .063 .358 .145
Soc. Resp Body Mvt Psybio Total AGE Soc Resp 1.00 Body Mvt .680 1.00 Psybio .664 .612 1.00 Total .852 .694 .628 1.00 AGE .217 .357 .344 .200 1.00 152
TABLE 52
Pearson correlation matrix: all deaf-blind children Relat Comm DrvMst Vocal Snd Spech Relat 1.00 Comm .861 1.00 DrvMst .730 .817 1.00 Vocal .338 .428 .385 1.00 Snd Spech .131 .147 .115 .501 1.00 Soc Resp .680 .797 .820 .366 .065 Body Mvt .742 .773 .747 .374 -.009 Psybio .609 .587 .629 .429 -.020 Total .882 .866 .846 .673 .418 AGE .177 .282 .068 .165 .027
Soc. Resp Body Mvt Psybio Total AGE Soc Resp 1.00 Body Mvt .682 1.00 Psybio .494 .740 1.00 Total .792 .806 .693 1.00 AGE .327 .231 -.026 .264 1.00
TABLE 53
Pearson correlation matrix: mentally retarded children Relat Comm DrvMst Vocal Psybio Relat 1.00 Comm .117 1.00 DrvMst .064 .887 1.00 Vocal .041 .881 .971 1.00 Psybio .114 .917 .925 .948 1.00 Total 5 .230 .927 .945 .955 .973 153
TABLE 54
Pearson correlation matrix: rubella deaf-blind children Relat Comm DrvMst Vocal Snd Spech Relat 1.00 Comm .880 1.00 DrvMst .763 .806 1.00 Vocal .296 .474 .384 1.00 Snd Spech .222 .356 .223 .569 1.00 Soc Resp .719 .770 .785 .446 .235 Body Mvt .758 .735 .718 .350 .165 Psybio .575 .487 .559 .221 .041 Total .872 .897 .864 .583 .503 AGE .063 .163 -.117 .203 .031 Total 5 .436 .380 .464 .458 .189
Soc. Resp Body Mvt Psybio Total Total 5 Soc Resp 1.00 Body Mvt .610 1.00 Psybio .394 .690 1.00 Total .815 .817 .623 1.00 AGE .191 .163 -.186 0.073 Total 5 .465 .314 .202 .486 1.00 154 TABLE 55
Pearson correlation matrix: non rubella deaf-blind children Relat Comm DrvMst Vocal Snd Spech Relat 1.00 Comm .809 1.00 DrvMst .678 .855 1.00 Vocal .563 .653 .595 1.00 Snd Spech -.075 -.221 -.003 .204 1.00 Soc Resp .597 .877 .898 .598 -.131 Body Mvt .782 .898 .809 .742 -.099 Psybio .719 .811 .748 .842 -.066 Total .762 .859 .854 .865 .220 AGE 0.022 0.419 .272 .071 -.223 Total 5 .788 .838 .731 .830 -.036
Soc. Resp Body Mvt Psybio Total Total 5 Soc Resp 1.00 Body Mvt .827 1.00 Psybio .688 .825 1.00 Total .828 .900 .847 1.00 AGE .405 .192 .115 .193 Total 5 .747 .862 .798 .904 1.00
(7) The third hypothesis investigated whether the developmental progression within the components of the BRIAAC is the same in the low functioning deaf-blind children as it is in autism and, if not, what is the nature of differences in progression. The null hypothesis proposed is that there are there are no significant differences in the developmental 155 progression within the components of the BRIAAC in the low functioning deaf-blind and autistic children. In order to investigate the progression on different levels of each component scale of the BRIAAC for the autistic and the deaf-blind, the scaling procedure devised by Leik and Matthews (1968) was utilized.
The results of the Leik and Matthews (1968) analysis of the eight BRIAAC scales is presented in Table 55. Before discussing the statistical findings, an explanation of the different tests of significance is in order. The Leik and Matthews is a Guttman-like scale which does not assume however, that the individual scoring at given levels have also gone through all lower levels. The z score tests whether the ordering of levels differs significantly from chance. The Rt tests how far the obtained ordering of scores differs from an ideal ordering, regardless of the number of children scoring at each level. The PRE yields the same information but takes the number of children at each level into account. An error represents an unscored level within the range of scored levels for a given child; e.g., if a boy receives points on levels 2, 3, 4, and 6, he has one error; if he receives points on levels 2, 4, and 7, he 156 has three errors. An ideal ordering of levels would contain no errors; i.e., all the levels scored for all the children would be contiguous. In essence, Rt and PRE are statistical techniques evaluating BRIAACs approximation to an ideal, errorless ordering of levels.
For the purpose of this test the deaf-blind were not further divided into rubella and non-rubella because of the small number of non-rubella children.
The developmental progression of the deaf-blind and autistic groups may seem similar to each other in terms of the total of mean errors for all the scales but, upon further examination, the mean errors are found to be not equally distributed on the various scales across the two groups. Further, the ordering of levels within the scales also show differences. The following results show the greater variability in the growth patterns or the sequencing of development in the two groups.
Overall the total of mean errors on all scales for the deaf-blind group is 6.92 (mean of mean errors .865) and for the autistic group 5.89 (mean of mean 157 errors .736). Greater disparity in the mean errors between the deaf-blind and autistic groups is noted in relationship scale: .60 and .11 respectively; social responsiveness: .52 and .83 respectively; and psychobiological: 3.34 and 2.32 respectively.
The data were visually inspected for possible differences in patterning of levels scored between the deaf-blind and the autistic groups. There were more deaf-blind children scoring on the lowest levels (1 and 2) on the following scales: communication, sound and speech reception, and body movement. Inspection also indicated differences in patterning within certain scales. Differences in errors of sequencing between the two groups occurred in relationship: level 4; vocalization: level 5; sound and speech level 3; social responsiveness: levels 3 and 5; body movement level 4; and psychobiological levels 2 and 6. In all these levels the deaf-blind groups had more errors.
the last hypothesis concerned with the question of whether there is a qualitative difference in the development of low functioning deaf-blind children when compared with normal children, as there are when autistic children are compared with normal. The null 158 hypothesis was that there are no differences in the development of low functioning deaf-blind children when compared with normal children.
This comparison of initial and other levels that may have been skipped by the deaf-blind children as is the case with normal children (Wenar et al., 1986) is done by comparing pattern of responses at different levels of each scale for each child's protocol in each of the groups.
The total of the mean errors on the BRIAAC scales for the deaf-blind is 6.92 (mean of mean errors .865) which is much higher than any of the mean error scores obtained by normal children. Normal 3-month-old children scored total of 3.4 mean errors (mean of mean errors .48), 12-month-old children scored 2.84 mean errors (mean of mean errors .3), 24-months-old children scored 2.27 mean errors (mean of mean errors .28) and 36-month-old children scored 1.38 mean errors (mean of mean errors .17). On each individual scale, the deaf-blind consistently had higher mean errors than any normal children's group. 159 Unlike the results of normal 3-month-old children (Wenar at al., 1986), who did not score on levels 1 and 2 of the relationship scale, and level 1 on communication, sound and speech reception, and social responsiveness, the deaf-blind group consistently scored on the lowest levels throughout all the scales confirming earlier observations of greater disturbance. These comparisons also indicate greater variability in the developmental sequencing of deaf-blind children than normal children of any age. 160 TABLE 56 LEIK AND MATTHEWS TEST Autistic and Deaf-Blind children's data from present study in comparison to mean of mean errors of normal children's data from DCAC study and Kalish study
SCALE Z Rt PRE Mean Group
Relationship Deaf-Blind 10.12 0.94 0.82 0.60 Autistic 8.71 0.98 0.95 0.11 Normal children DCAC 0.01 Kalish 0.09 Communication Deaf-Blind 13.04 0.98 0.96 0.15 Autistic 7.29 0.95 0.85 0.47 Normal children DCAC 0.26 Kalish 0.04
Drive Mastery Deaf-Blind 12.81 0.97 0.92 0.26 Autistic 8.12 0.98 0.94 0.17 Normal children DCAC 0.30 Kalish 0.03
Vocalization Deaf-Blind 9.56 0.94 0.80 0.59 Autistic 5.18 0.94 0.77 0.58 Normal children DCAC 0.75 Kalish 0.39 161 TABLE 56 (continued) LEIK AND MATTHEWS TEST Autistic and Deaf-Blind children's data from present study in comparison to mean of mean errors of normal children's data from DCAC study and Kalish study on each BRIAAC scale
SCALE Z Rt PRE Mean errors Group Sound and Speech Deaf-Blind 6.16 0.94 0.76 0.63 Autistic 6.6 0.92 0.75 0.73 Normal children DCAC 0.10 Kalish 0.05
Social Responsiveness Deaf-Blind 8.76 0.94 0.83 0.52 Autistic 7.85 0.91 0.76 0.83 Normal children DCAC 0.44 Kalish 0.30
Body Movement Deaf-Blind 11.61 0.92 0.75 0.83 Autistic 8.56 0.93 0.79 0.68 Normal children DCAC 0.14 Kalish 0.11
Psychobiological Deaf-Blind 3.34 Autistic 2.59 0.76 0.23 2.32 Normal children DCAC 1.64 Kalish 1.15 162 TABLE 57
LEIK AND MATTHEWS TEST Normal Children's data from DCAC study (n=160) and Kalish Study (n=150) (Wenar, Ruttenberg, Kalish and Wolf, 1986 p.325-327)
SCALE Rt PRE Mean errors Group
Relationship DCAC study 3 mos 2.50 .99 .92 .10 6 mos 5.20 1.0 1.0 0 9 mos 5.20 1.0 1.0 0 12 mos 6.10 1.0 1.0 0 15 mos 6.55 1.0 1.0 0 18 mos 5.76 1.0 1.0 0 21 mos 6.02 1.0 1.0 0 24 mos 6.19 1.0 1.0 0 Kalish study 12 mos 8.94 0.99 0.92 0.23 24 mos 10.65 0.99 0.98 0.05 36 mos 10.40 1.00 1.00 0.00
Communication DCAC study 3 mos 5.80 1.0 1.0 0 6 mos 7.30 .99 .97 .10 9 mos 8.05 .98 .94 .20 12 mos 5.71 .95 .89 .45 15 mos 8.33 .98 .94 .20 18 mos 7.52 .95 .89 .45 21 mos 7.83 .97 .92 .25 24 mos 8.40 .95 .85 .50
Kalish study 12 mos 9.71 0.99 0.99 0.03 24 mos 10.32 0.99 0.99 0.02 36 mos 9.37 0.99 0.97 0.08 163
(TABLE 57 continued) LEIK AND MATTHEWS TEST Normal Children's data from DCAC study (n=160) and Kalish Study (n=150) (Wenar, Ruttenberg, Kalish and Wolf, 1986 p.325-327)
SCALE Z Rt PRE Mean Group
Drive Mastery DCAC study 3 mos - - - - 6 mos 4.10 .93 .77 .65 9 mos 5.17 .93 .79 .75 12 mos 6.50 .94 .84 .50 15 mos 7.00 .98 .95 .15 18 mos 7.81 .99 .97 .15 21 mos 6.74 .99 .97 .10 24 mos 5.92 .99 .96 .10
Kalish study 12 mos 9.24 0.99 0.98 0.06 24 mos 11.89 0.99 0.98 0.05 36 mos 9.7 1.00 1.00 0.00
Vocalization DCAC study 3 mos 3.42 1.0 1.0 0 6 mos 5.74 1.0 1.0 0 9 mos 6.49 .99 .97 0.10 12 mos 6.40 .95 .86 0.45 15 mos 4.07 .83 .59 1.65 18 mos 4.10 .83 .49 1.65 21 mos 6.03 .89 .68 1.10 24 mos 5.90 .90 .71 1.10
Kalish study 12 mos 7.86 0.99 0.90 0.28 24 mos 9.80 0.99 0.85 0.50 36 mos c e i 1 i 1 i n g 164 (TABLE 57 continued) LEIK AND MATTHEWS TEST Normal Children's data from DCAC study (n=160) and Kalish Study (n=150) (Wenar, Ruttenberg, Kalish and Wolf, 1986 p.325-327)
SCALE Z Rt PRE Mean errors Group Sound and Speech DCAC study 3 mos 3.18 .95 .74 0.5 5 6 mos 5.0 .99 .94 0.1 5 9 mos 7.0 1.0 1.0 0 12 mos 7.88 .99 .99 0. 05 15 mos 6.68 1.0 1.0 0 18 mos 8.09 1.0 1.0 0 21 mos 7.44 .99 .99 0. 05 24 mos 8.24 1.0 1.0 0.
Kalish study 12 mos 9.50 0.99 0.97 0.09 24 mos 9.22 0.99 0.99 0.02 36 mos c e i 1 i
Social Responsiveness DCAC study 3 mos .69 .98 .50 .20 6 mos 2.79 .93 .64 0.70 9 mos 4.23 .90 .68 0.95 12 mos 4.02 .92 .70 0.70 15 mos 5.42 .95 .85 0.40 18 mos 10.0 .98 .91 0.30 21 mos 6.58 .98 .95 0.15 24 mos 6.49 .98 .95 0.15
Kalish study 12 mos 7.79 0.99 0.84 0.51 24 mos 10.56 0.99 0.92 0.28 36 mos 10.08 0.99 0.96 0.12 165 (TABLE 57 continued) LEIK AND MATTHEWS TEST Normal Children's data from DCAC study (n=160) and Kalish Study (n=150) Body Movement DCAC study 3 mos 8.02 .99 .99 0.10 6 mos 8.95 .98 .99 0.10 9 mos 9.46 .99 .99 0.05 12 mos 9.36 .99 .94 0.10 15 mos 9.09 .98 .94 0.20 18 mos 8.67 ,97 .92 0.25 21 mos 8.24 .98 .95 0.15 24 mos 8.94 .98 .94 0.20
Kalish study 12 mos 12.75 0.99 0.94 0.20 24 mos 12.13 0.99 0.99 0.05 36 mos 10.88 0.99 0.98 0.08
Psychobiological DCAC study 3 mos 2.73 .84 .47 1. 55 6 mos 2.71 .77 .30 2. 20 9 mos 3.66 .80 .39 2. 00 12 mos 4.88 .79 .36 2. 10 15 mos 4.25 .84 .48 1. 60 18 mos 1.63 .87 .54 1. 25 21 mos 4.57 .86 .54 1. 30 24 mos 1.79 .88 .60 1. 15
Kalish study 12 mos 7.33 0.78 0.64 1.07 24 mos 8.16 0.88 0.78 1.30 36 mos 4.69 0.89 0.64 1.10 CHAPTER V
DISCUSSION
The research strategy involved comparing low functioning deaf-blind and autistic children for variables assessed by the Behavioral Rating Instrument for Autistic and other Atypical Children. Mentally retarded, non autistic children served as a control for mental retardation in the low functioning deaf-blind group. The development of the low functioning deaf-blind children was also compared with that of normal infants/toddlers.
A detailed examination of the significant differences and similarities among the groups studied in light of the four specific questions that have been asked of this research is presented. The findings of the research are then discussed in the context of intervention strategies and possible future directions for research.
Age and sex related differences in the BRIAAC performances of the autistic and the deaf-blind groups were also investigated. A crucial question asked in developmental research is how do advances in age correlate
166 167 with performance on behavioral variables. Wenar et. al, (1986) found that the normal children's advances in age are highly correlated with BRIAAC behavior variables. Correlation coefficients for the normal children ranged from .76 to .86 on all scales and all were significant beyond .001 level of confidence for the Kalish data (Wenar, Ruttenberg, Kalish and Wolf, 1986) . The results of the correlation of BRIAAC variables of deaf-blind groups with their chronological ages show remarkable parallels with those found for autistic children as opposed to normal children. The relation between age and BRIAAC performance for the deaf-blind children and for the autistic children is a weak one. None of the correlations for the deaf-blind and the autistic children are significant. Therefore the behavior patterns of the children in these groups who ranged from 5 to 12 years in age, are indeed unique to these groups and could not be the result of maturation.
In comparing the BRIAAC performance of boys and girls in the autistic and the deaf-blind groups, no significant sex differences were obtained. These findings do not support previous findings where autistic girls tend to be more seriously affected (Lord, Shopler and Revick, 1982 and Wing, 1981). In patterning of responses only the rubella deaf-blind boys and girls were different on vocalization 168 (p<.017) and sound and speech scales (p<.013). Boys scored higher on both on vocalization and sound and speech (mean 22.76, and SD 8.01 for boys; and mean 16.9 and SD 4.25 for girls).
The first question that this study set out to answer concerned the overall degree of disturbance as measured by the BRIAAC in low functioning deaf-blind and autistic populations with non-autistic mentally retarded children serving as control. An overall MANOVA comparing autistic, deaf-blind and mentally retarded groups cumulative scores on 5 BRIAAC scales, and another overall MANOVA comparing cumulative scores for all the eight scales for the autistic, rubella deaf-blind, and non-rubella deaf-blind yielded significant differences between all diagnostic groups. The autistic groups cumulative score was 364.79 compared to the deaf-blind group which scored 291.38. The overall severity of disturbance is greater in the deaf blind group. The variability in the distribution of scores are different for the two groups. The standard deviation for the autistic group is 148.97 and that of deaf-blind children 80.75 (significant at P=<.01). By contrast, the mentally retarded group's cumulative score of 316.5 on 5 scales are significantly higher than for any other group (autistic: 206.48, deaf-blind: 179.42, rubella: 174.96 and 169 non rubella: 188.69). This indicates that this group was least disturbed. This also indicates that the findings on the deaf-blind were not due to mental retardation alone.
The second question that was investigated concerned whether component behaviors comprising BRIAAC are equally affected in the low functioning deaf-blind and autistic children or whether there is a difference in the patterning of these components. In the latter case, what is the nature of the different pattern?
Based upon the many univariate analyses of variances comparing two groups at a time, patterns of responses on the BRIAAC component become obvious. When the autistic group is compared with with deaf-blind as a group, significant differences are seen in four of the eight scales: vocalization, sound and speech, social responsiveness, and body movement. In every instance the deaf-blind group scored lower. There are no differences in relationship, communication, drive for mastery and psychobiological scale. Comparing the autistic group with the rubella deaf-blind group yields the same results as with the deaf-blind group as a whole. However, when the autistic children are compared with the non-rubella deaf blind group, only two scales, social responsiveness and 170 body movement are significantly different. No differences are seen in relationship, communication, drive for mastery, vocalization, sound and speech reception and the psychobiological scale.
When the rubella and the non-rubella deaf-blind groups are compared, significant differences are found only on the vocalization and sound and speech scales with no differences in relationship, communication, drive for mastery, social responsiveness, body movement, psychobiological and the total cumulative score.
Comparisons were also done with the mentally retarded group and each of the other groups on the five scales. In comparing the mentally retarded group with the autistic group on five scales, significant differences are noted in relationship, communication, and psychobiological scales, and no differences exist in drive for mastery and vocalization. In every case the mentally retarded group scored higher. An identical pattern is obtained when the non-rubella deaf-blind are compared with the mentally retarded. The rubella deaf-blind group yielded significant differences on all five scales when compared with the mentally retarded group. 171 In looking at similarities, the non-rubella deaf-blind come very close to the characteristics of autistic group with similar behaviors on six out of eight scales. The rubella children are similar on four scales out of eight The mentally retarded resemble autistic group on only two of the five scales. When these similarities are seen against the backdrop of accepted classical criteria of autism: abnormalities of development of - communication, severe disturbance of social relatedness, ritualized compulsive activities, and abnormal responses to visual, auditory and tactile stimulii, the mentally retarded children do not fulfill the core criteria of autism except in drive for mastery. On the other hand, the deaf-blind groups and, particularly, the non-rubella deaf-blind group seem to satisfy these criteria.
As we have seen so far, it seems that the non-rubella deaf-blind and rubella deaf-blind, in spite of distinct etiologies and differences in the extent of brain damage, perform very similarly. The marked similarities between these groups leads us to once again look upon the primacy of intactness of visual and auditory input as one important ingredient in the unfolding of the events of development. The similarity of their behavioral characteristics is contrasted by the massive invasion and damage done to the 172 nervous system of the rubella children by viral infection. Non-rubella deaf-blind children only scored significantly higher than the rubella victims on vocalization and sound and speech. The differences might be explained by the fact the non-rubella children have relatively less auditory involvement in comparison to the rubella victims. The presence of retinal atrophy or retinal detachment does not simultaneously involve auditory impairment along with the visual. Thus, auditory feedback so essential in the shaping early babbling, and the ability to respond to speech and sound, are essential in the non-rubella children's higher scores for the two variables: vocalization and sound and speech reception. At about three to four months, children universally begin to babble sounds that approximate speech. The onset of babbling occurs at the same time even in children who are deaf or who have deaf-parents who cannot response to their babbles. While babbling in the hearing children gradually increases until it peaks between nine and twelve months, the babbling of the deaf child soon ceases, most probably because of lack of auditory feedback (Lenneberg, Rebelsky, and Nicholas, 1965). It remains to be seen whether the non-responsiveness of the rubella child to speech and sounds is indicative of negativism or an inability to respond that is mistaken for "passive" negativism. 173
Some studies have linked viral invasion of the brain and the subsequent massive brain damage as possible cause of higher incidences of autistic pathology in rubella deaf blind children. Yet, despite their etiological diversities, the rubella and the non-rubella deaf-blind groups present many similarities among themselves and to those of autism. This similarity of behaviors to autism, and more closely the greater similarity of the non-rubella group to autism, leads to skepticism at accepting massive viral infections as a possible precursor to autism. The only commonality between the two deaf-blind groups is their lack of distal receptors and this might be an effect that culminates in the observed similarity of their common clinical picture with autism. A clearer picture of possible autism in deaf blind group cames from the qualitative analyses of their BRIAAC responses and their comparisons with normal children's BRIAAC responses.
The third question asked concerned the developmental progression within the components of BRIAAC in low functioning deaf-blind children and autism. If not the same, then what is the nature of differences in progression? The results of the Leik and Metthews analysis were used to investigate the patterns of developmental 174 progression. For the purpose of this test the deaf-blind were not further divided into rubella and non-rubella because of the small number of non-rubella children.
The developmental progression of the deaf-blind and autistic groups may seem similar to each other in terms of the total of mean errors for all the scales but, upon further examination, the mean errors are found to be not equally distributed on the various scales across the two groups. Further, the ordering of levels within the scales also show differences. The results show greater variability in the growth patterns or the sequencing of development in the two groups.
The errors of sequencing that result from skipping earlier levels within each BRIAAC scale indicate variability in the sequencing of growth progression. Overall the deaf-blind group had the highest number of total mean errors on all scales: 6.92 (mean of the mean errors is .865). The total mean errors on all scales for the autistic group is 5.89 (mean of the mean errors is .736). In comparison normal children had the least amount of errors. Normal 3-month-old children had 3.4 total mean errors for the scale (mean of the mean errors is .48), normal 12-month-old normal children had 1.32 total mean 175 errors for the scale (mean of the mean errors is .188), 24- months-old children had .97 total mean errors for the scale (mean of the mean errors is .138), and 36-months-old children had 1.38 total mean errors for the scale (mean of the mean errors is .197).
The greater number of mean errors in the deaf-blind group once again point to the greater disturbance in the deaf-blind children in comparison to autistic group. This disturbance is evident in the greater variability of sequencing of behavioral patterns in both the groups.
The mean errors are not similar across the two groups on some of the scales. Prominent differences are in relationship, vocalization, sound and speech, social responsiveness, body movement and psychobiological scales.
On the relationship scale mean errors were . 60 for deaf-blind and .11 for the autistic group. The large number of errors for the deaf-blind group shows that that the progression of growth on this scale has greater variability than that of the autistic. One reason for this variability might be the faithful following of the autistic children to the ordering of levels which were constructed and standardized based upon the patterns of autistic 176 development and thereby less errors. Yet, upon visual inspection of the responses, the variability of the sequencing is seen to be due to the high number of deaf blind children skipping level 4 of this scale. Level 4 marks a child's ability to attend to a person at a distance of approximately six feet or more and to sustain eye contact at this distance, if it is made. The child can tolerate nearness if he/she can back up into a person.
The inability to gauge people at distance due to sensory limitations might lead to this behavior not being evidenced in the developmental progression of the deaf blind children. Their resistiveness to relationship may not necessarily be a sign of active or passive resistance as it is in autism, but a mark of tactile defensiveness associated with deaf-blindness. Failure to actively search out attending persons for comfort, approval, help or play in the deaf-blind most logically points to a lack of capability rather than an underlying deficit. Wing (1969) notes "deaf-blind children as a group did not avoid physical contact and had less attachment to objects as contrasted with autistic children". Failure to score on the higher levels of this scale as well as on most other scales may imply failure on the part of these children to assimilate the aspects of approval and disapproval of 177 behaviors and later share experiences due to the narrow range of experiential learning.
On the vocalization scale, the mean errors between the autistic and the deaf-blind children are equal for both the groups (.58), but the sequencing has more errors in the deaf-blind at level 6 which marks of echolalia. No errors for the autistic group occured at this level. Here again words cannot be repeated by a child who cannot hear them. The element of auditory feed-back for speech and sound formation is lacking in the sample of deaf-blind children. Most deaf-blind children are indicated to be non-vocal, with others may make gutteral or strained sounds, and variations in volume or pitch or intonation. Their lack of consistent movement to musical babbling, single word utterances, echolalia once again does not necessarily indicate a basic deficit of autistic quality or form but rather their lack of sensory input so vital for phonemes to form words. Residual hearing can account for limited final levels reached by some deaf-blind children on this scale.
BRIAAC was modified in terms of adding two scales evaluating communication in terms of sign language: sign/receptive and sign/expressive. These scales were used for the deaf-blind version to supplement sound and speech 178 reception (Schein, 1981) . No comparison of these scales has been undertaken in this study. However, looking over the test scores, many deaf-blind children scored on higher levels than on sound and speech reception scale.
The mean numbers of errors on speech and sound reception for the deaf-blind were .65 and for the autistic .73. Level 4 on this scale evidenced high number of errors in the deaf-blind group. This level is about a child's awareness of sounds by reacting to it. The failure to score on this level does not necessarily point to the autistic characteristic of indifference or what meaning the sound may have. The deaf-child does not necessarily indicate indifference to human sounds. He simply does not hear them.
Deaf-blind children show signs of awareness of their basic needs and social requirements, as measured on the social responsiveness scale, which measures social requirements regarding self-help functions. However, they do not evidence a growing repertoire of social behaviors as indicated in their failure to score on the higher levels. Interestingly, unlike the autistic child they were not oblivious to social requirements nor did they have idiosyncratic, bizarre ritualistic behaviors. This aspect is related to the higher number of errors noted on level 3 179 in the deaf-blind children BRIAAC performance as opposed to the autistic. This level is marked by idiosyncratic, bizarre often auto erotic behaviors which only secondarily involve the actual performance of the social function. Specific behaviors are repetitive and ritualistic but not complex and sophisticated; examples are placing spit on a series of selected objects, or bizarre finger and hand movements at meal time. This common characteristic of autistic children is not highly evidenced in the deaf blind.
On the Social responsiveness scale the mean errors for the autistic group were .82 and for the deaf-blind group .50. Level 5 of this scale evidences errors of sequencing by half of the autistic children as opposed to only one deaf-blind child. This level marks the beginnings of acceptance of social requirement. The child superficially mirrors actions of peers and adults. There is some awareness and anticipation of the schedules, routines, specific requirements and requests, but the child needs to be reminded. Deaf-blind children do not evidence the non- responsiveness forementioned. In fact, on this level, more deaf-blind children scored than the autistic. 180 On the body movement scale the mean errors for the autistic group were .67 and for the deaf-blind group .84. Differences in the sequencing pattern were also seen on this scale on level 4 between the deaf-blind and the autistic groups. More deaf-blind children skipped this level. This level is related to incipient action indicated in body position and tone. The body movement scale as a whole may present problems despite the scoring at other levels. The impact of being deaf and blind hinders proper vestibular, kinesthetic and proprioceptive development and integration and, as a result, no matter how similar a picture to that of the autistic child, the non-intactness of skeleto-muscular control apparatus of the deaf-blind bears heavily on the response pattern so seen.
In terms of errors of sequencing within the psychobiological scale, the deaf-blind group as a whole had the most errors in comparison to the autistic (3.34 and 2.32 respectively). High rates of errors occured at levels 2, 3, 4, 5, 6 and 7 in both the groups. However, greater number of errors occurred in the deaf-blind group as compared to the autistic on levels 2 and 6. In sequencing the behavioral pattern deaf-blind children skipped the oral mouthing and sucking stage that is seen in most of the autistic children's group. This level marks persistence and 181 extensive indiscriminate mouthing, licking, sucking, blowing, tasting; frantic, bizarre or prolonged insistence on limited food types, brands, consistencies; no interest in chewing; and choking and gaging on food. By text book accounts, the proximity receptors— gustatory and olfactory sensations make up for the distal receptors in the deaf blind children. This observation of less of oral mouthing seems to contradict hypotheses of compensatory sensory adaptation in the deaf-blind. Level 6 is a stage of interest in phallus. For some unknown reason, the deaf blind children, as opposed to the autistic children, did not evidence masturbatory activity.
Thus far we have seen that there are subtle differences in the behavioral patterns of sequencing between the deaf-blind and the autistic groups. There are many similarities that may be understood better in terms of overlap of behaviors rather than as belonging to a diagnostic entity. Wenar et al. (1986) explored the differences in the type of developmental progression by comparing the BRIAAC responses of autistic children with that of normal children and found that these groups start their development at different levels. The omission of initial levels on many scales by normal children point to a divergent path of developmental taken by normal and 182 autistic children. Can such a pattern for the deaf-blind exist whereby the development of normal children is not followed by this population. Thus the last question was posed:
The last question in this study concerned with evidence of a qualitative difference in the development of low functioning deaf-blind children when compared with normal children, as there is when autistic children are compared with normal children (Wenar, et al., 1986).
Results to this question must be cautiously interpreted because the deaf-blind sample in this study did not involve any children below 5 years of age. Whether or not the earlier levels that seem to have been sparsely scored or skipped in the deaf-blind sample are representative of the entire population of such children cannot be made without examining data of deaf-blind infants and toddlers. In addition, the BRIAAC scales have been constructed or standardized on an autistic population. Plus it may not include behaviors characteristic of normal population. Therefore similar responses of the deaf-blind and normal children do not necessarily mean that the deaf blind children are developing like normal children. To make such a statement, one would need an instrument standardized 183 upon normal children. These two reservations should be kept in mind.
However, based upon the assumption that these deaf blind children are very low functioning comparable to three year old children because of the fact that they require constant supervision, we may ask how are normal children similar to the deaf-blind children? The patterning of responses of the normal children is not found in the development of deaf-blind children. Normal children who were 3 months old did not score on levels 1 and 2 of the relationship scale. Fifteen percent of the deaf-blind children scored on level 1 and 39 percent scored on level 2 of the relationship scale. Similarly, whereas no normal 3 month child scored on first levels of communications, sound and speech and social responsiveness, deaf-blind children consistently scored on these levels. Conversely, it can be said that normal children like the deaf-blind score on lowest levels of the vocalization, body movement, and psychobiological scales. Thus, indicating as Wenar et al. (1986) put it, "...normal children at times would be non- vocal when vocalization would be appropriate, their bodies would be excessively tense or limp, and they would evidence auto-erotic behaviors and primitive rages" (p. 330). 184 The implications of this study are many fold. The observation of diagnostic overlap of various developmental pathologies has once again been confirmed. Yet overlap should not be taken to mean identity. The numerous analyses of the BRIAAC scores, the discriminant plotting of the diagnostic entities, and the post hoc tests of group membership against predicted show us that there are clusters of behavioral patterns that are unique to each of the diagnostic groups studied here. At the same time the long held unique characterizations of autism have been demonstrated to be indeed unique. The true total picture of autism based upon the BRIAAC scales has not been demonstrated in any of the other pathologies compared to autism in this study. However, time and again it has been demonstrated that many other disorders including the deaf blind children share many behavioral features with autism but which do not fulfill the complete set of behaviors associated with autism. On the basis of the results of this study, it cannot be said that autism is a by product of a specific known pathology, which in our case is -congenital rubella. The so called neurologically impaired "autistic" children must be looked upon as presenting certain subclusters of symptoms, as in the case of the rubella children, that are more logically derivative of gross disturbances of sensory and motility processes and 185 structures. Nor is it convincing to apply labels like "partial autistic syndrome" when obviously the developmental unfolding of a nascent child is contrived in a muted world of sights and sound which inherently then determine a path predictably gone awry. The degree of comparability of behavioral domains between the grossly neurologically impaired rubella children and the non- rubella deaf-blind children also argues against a special relation between rubella and autism. The uniqueness of the autistic population answers many questions and poses many others. But the nature of the basic deficit in autism as a precursor to the consistent and well defined syndrome continues to elude empirical investigation.
The performance of a group of mentally retarded children served as controls for the measurements and the results convincingly point to the fact that autistic children, rubella children and other non-rubella deaf-blind children share only few characteristics with the retarded child when it comes to five psychological variables tapped by the BRIAAC. The mentally retarded child is less severely disturbed. The intercorrelations among the BRIAAC scales in the mentally retarded group point to another unique characteristic that is not seen in the autistic and the deaf-blind. The degree of relationship to an adult is not 186 related to the competencies in the area of communication, drive for mastery, vocalization or psychobiological development. Relationship to an adult takes its own "single strand" growth pattern.
The evaluation of the similarity of pathology between autistic and deaf-blind can be done in another way. The Pearson intercorrelations that have been computed between the BRIAAC scales across the groups show that there are differences in the globality of integration of the different behavioral domains in these pathological groups. This test of internal consistency shows a considerable degree of compartmentalization in the deaf-blind groups as compared to the autistic. The development of the autistic children no matter how unique, has a uniformity of integration. There seems to be a glue that has held different domains in dynamic cohesion in spite of the deficit that still eludes us. The deaf-blind seem to have an uneven weak force of integration in which development in one area is negatively correlated with development in another.
In conclusion, based upon the multi-faceted analyses so presented, it seems that overall the autistic- like behaviors seen of the deaf-blind children are not 187 equivalent to the syndrome of autism as many clinical studies have suggested. Deaf-blind children may develop autism as may any other populations or cultures. Even though their observed behavior may be judged to be autistic, the underlying causes of these characteristics has not been tested. The basic deficit in autism which still is not clearly understood may not necessarily be the cause of autistic-like behaviors in the deaf-blind children. Observation instruments like the BRIAAC only tap into observed behaviors. The social aloofness of the autistic child and the social aloofness in the deaf-blind can be recorded as behaviorally the same, but the behavioral ratings cannot tell us what determines this lack of capacity autistic children and the inability in the deaf-blind. Concrete answers may still come from comparisons of such test data that tap into features like abnormalities in appreciation of socioemotional cues, cognitive deficits in the abstraction of meaning and language related cognitive impairments.
Yet, if it is not autism, then what is the nature of the pathology that we see so often in the deaf-blind children. The DSM III-R criteria for pervasive developmental disorder can be imposed upon the unfortunate victims of rubella and other sensory impairments, but it 188 would be unjust to do so without taking the experiential deficits and the kind of variables described above.
Nevertheless the true test of the autistic-like features of the deaf-blind children ultimately impacts upon intervention. If it is not autism in part or full blown, then how fast and in what manner can remediation be initiated? Studies have been done on instructing deaf blind, by treating them as non autistic but experientially deprived students, and the results are encouraging. Their progress is gauged in micometers but with the aid of sensitive tools that can discriminate very small increments of change future researches will have to press this matter of therapeutic progress further. Worth mentioning at this point is the AIM curriculum (Schein, 1981) that combines the assessment model with intervention for extremely atypical children including deaf-blind, and early results seem encouraging. Such a teaching strategy has to be contrasted with the commonly accepted ones found in remedial text books that lay a heavy emphasis on the premise that deaf-blind children are basically sensorily deprived and sensory stimulation is the course of intervention. Such remedies say little in terms of possible underlying differences from normal children or presenting a 189 unique pathology of psychological integration and experiential deficits.
It can be speculated that deaf-blind children initially start along the similar pathways that normal children take, but have a very slow rate of growth and a variable one that has low caps across many domains. They tend to shed earlier behaviors but soon fail to add new ones and as a result have been mistaken as showing many symptoms characteristic of autistic pathology without really being autistic.
There have been limitations in this study. The use of archival data brings with it many issues that cannot be easily resolved. The data on the children used in this study is old, in the case of the mentally retarded children it is 17 years old and for the autistic population, the data is 13 years old. Over time, the population mix of any diagnostic category can inevitably change due to revised classification techniques, newer criteria for classifications and changing test norms. In the case of the mentally retarded children, many genetic, chromosomal and other physiological disorders may not now be represented as much in the newer populations as was the case 18 years ago. Genetic counseling, pre-natal detection, prevention and 190 intervention for a host of disorders have altered representations of various kinds of etiologies in the mentally retarded group. Further, newer programs with emphases on early stimulation and intervention have a determinant effect on developmental progression that was not available many years ago. In the same manner, the strict DSM-III criteria for autism, and even Kanner's classical symptoms are no longer exclusive. DSM-III (R) does not limit the age of onset of autistic pathology to before 30 months of age. The changing clinical picture of any pathology may that be mental retardation or autism requires caution in interpreting findings that are based upon old data representing a different flavor of diagnostic constituents. Validation of these results using newer population cannot be overlooked.
The unavailability of data on the full eight scales of the BRIAAC for the mentally retarded control group leaves much to be discovered not only about their performance but also about comparative analyses with other diagnostic groups.
Similarly, conclusive findings on the developmental progression of the deaf-blind cannot be made without data on deaf-blind infants and toddlers. Day-to-day observations 191 of deaf-blind subjects whose data was used could help answer questions which the present data cannot, e.g., are there differences in styles of reacting to adults that have not been tapped by the BRIAAC? Behavioral data needs to interpreted in its ecological reality which, of course, is not available when archival data is used.
The kinds of comparisons as have been done in this study need to be made across a wider variety of pathologies that are pervasive in nature, e.g., childhood schizophrenia, various forms of mental retardation and aphasics; and whose etiologies are diverse, e.g., genetic, physiological and trauma related. Only then can one pin point a specific problem afflicting a diagnostic group of children. Such comparisons then may be tested in terms of specific psychological problems of deeper cognitive and psychophysiological mediating components.
Last of all this discussion will be incomplete without saying something about the BRIAAC. Based upon the discriminant analysis and the post hoc classifications presented, the discriminant ability of the BRIAAC across the different diagnostic groups provides an indispensable tool in the quest of comparative studies of severe 192 pervasive pathologies, especially those that need to be studied in a developmental context. 193
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